Provider Demographics
NPI:1790297935
Name:DIAMOND MEDICAL GROUP
Entity Type:Organization
Organization Name:DIAMOND MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENERJI
Authorized Official - Middle Name:
Authorized Official - Last Name:GUDAPATI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-448-0369
Mailing Address - Street 1:3679 WAKEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-8708
Mailing Address - Country:US
Mailing Address - Phone:219-448-0369
Mailing Address - Fax:
Practice Address - Street 1:830 PARK EAST BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-0778
Practice Address - Country:US
Practice Address - Phone:219-448-0369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-27
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty