Provider Demographics
NPI:1508837048
Name:TREVINO, DIANE (DPM)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:TREVINO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 THORAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-1227
Mailing Address - Country:US
Mailing Address - Phone:210-391-8457
Mailing Address - Fax:
Practice Address - Street 1:177 THORAIN BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-1227
Practice Address - Country:US
Practice Address - Phone:210-391-8457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1622213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00398188OtherRAILROAD MEDICARE
TX018574601Medicaid
00107EMedicare ID - Type Unspecified
U92202Medicare UPIN