Provider Demographics
NPI:1467555680
Name:SMOGOR, DIANE (MNT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:SMOGOR
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 66664048
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46266-4048
Mailing Address - Country:US
Mailing Address - Phone:317-780-3333
Mailing Address - Fax:317-780-3345
Practice Address - Street 1:8051 S EMERSON AVE
Practice Address - Street 2:SUITE 340
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8600
Practice Address - Country:US
Practice Address - Phone:317-865-5904
Practice Address - Fax:317-865-5321
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001004A133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN182950FMedicare ID - Type Unspecified