Provider Demographics
NPI:1699827527
Name:SHAKTMAN, DIANE MERRIL (MD)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MERRIL
Last Name:SHAKTMAN
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 1:1009 N GEORGETOWN ST
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-3289
Mailing Address - Country:US
Mailing Address - Phone:512-255-1720
Mailing Address - Fax:512-244-8371
Practice Address - Street 1:150 SETTLEMENT DR STE E
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-9662
Practice Address - Country:US
Practice Address - Phone:512-303-3963
Practice Address - Fax:512-303-6366
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE66152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
TXB26374Medicare UPIN
TXPENDINGMedicaid