Provider Demographics
NPI:1538135603
Name:WETHERTON, DIANE K (MD)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:K
Last Name:WETHERTON
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 1:2307 S HIGHWAY 53
Mailing Address - Street 2:P.O. BOX 247
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-8568
Mailing Address - Country:US
Mailing Address - Phone:502-225-6277
Mailing Address - Fax:502-225-6278
Practice Address - Street 1:2307 S HIGHWAY 53
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-8568
Practice Address - Country:US
Practice Address - Phone:502-225-6277
Practice Address - Fax:502-225-6278
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35036208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65934945Medicaid
KYH40435Medicare UPIN
KY0679102Medicare ID - Type Unspecified