Provider Demographics
NPI:1477546539
Name:WOLFE, DIANA LEE (MD)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:LEE
Last Name:WOLFE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:LEE
Other - Last Name:DEMPSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-7728
Mailing Address - Fax:417-269-7729
Practice Address - Street 1:3801 S NATIONAL AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5210
Practice Address - Country:US
Practice Address - Phone:417-269-7728
Practice Address - Fax:417-269-7729
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002019572207R00000X
KS04-30347207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO611348OtherANTHEM
KS200003810AMedicaid
KS200003810BMedicaid
MO207626607Medicaid
MO151250009Medicare Oscar/Certification
MO207626607Medicaid
KS200003810AMedicaid