Provider Demographics
NPI:1508842311
Name:ICENOGLE LEUSCHEN, DIANE M (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:M
Last Name:ICENOGLE LEUSCHEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 MERTON MINTER
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4404
Mailing Address - Country:US
Mailing Address - Phone:210-617-5300
Mailing Address - Fax:210-949-3350
Practice Address - Street 1:7400 MERTON MINTER
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4404
Practice Address - Country:US
Practice Address - Phone:210-617-5300
Practice Address - Fax:210-949-3350
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ86002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJ8600OtherMEDICAL LICENSE
TX8D8214OtherMEDICARE ID - TYPE UNSPECIFIED
TXJ8600OtherMEDICAL LICENSE