Provider Demographics
NPI:1861458374
Name:THOMAS, DIANE SUE (MD)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:SUE
Last Name:THOMAS
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 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6655
Mailing Address - Fax:270-858-4607
Practice Address - Street 1:311 W HIGH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033
Practice Address - Country:US
Practice Address - Phone:270-692-5811
Practice Address - Fax:270-692-3863
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY325042080A0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64325046Medicaid
KY64325046Medicaid