Provider Demographics
NPI:1487654216
Name:SELDOMRIDGE, DIANNA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:LYNN
Last Name:SELDOMRIDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANNA
Other - Middle Name:LYNN
Other - Last Name:MIELE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 63362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3362
Mailing Address - Country:US
Mailing Address - Phone:919-684-8111
Mailing Address - Fax:
Practice Address - Street 1:2025 FRONTIS PLAZA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5663
Practice Address - Country:US
Practice Address - Phone:336-768-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00026710207W00000X
NC2009-00087207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPENDINGMedicaid
NC15162OtherBCBSNC
NCPENDINGMedicaid
I14476Medicare UPIN