Provider Demographics
NPI:1508854860
Name:ENNES, DIANA (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:ENNES
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:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48764-0779
Mailing Address - Country:US
Mailing Address - Phone:989-362-9859
Mailing Address - Fax:989-362-9862
Practice Address - Street 1:110 BEECH ST
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-8314
Practice Address - Country:US
Practice Address - Phone:989-362-9859
Practice Address - Fax:989-362-9862
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044652207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3370220Medicaid
B45095Medicare UPIN
MIOC56002035Medicare ID - Type Unspecified