Provider Demographics
NPI:1659365401
Name:MAINWOLD, DIANE HERMANIE (DO)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:HERMANIE
Last Name:MAINWOLD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 ISLAND VIEW DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-4346
Mailing Address - Country:US
Mailing Address - Phone:321-777-5442
Mailing Address - Fax:
Practice Address - Street 1:1318 S PINE ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3117
Practice Address - Country:US
Practice Address - Phone:321-952-9500
Practice Address - Fax:321-952-2299
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6956207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070207200Medicaid
FL46790YMedicare ID - Type Unspecified
FL070207200Medicaid