Provider Demographics
NPI:1891933032
Name:DIANNE MARTIN MD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DIANNE MARTIN MD PROFESSIONAL CORPORATION
Other - Org Name:DIANNE MARTIN MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MD/PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-541-9154
Mailing Address - Street 1:5670 CAITO DR
Mailing Address - Street 2:SUITE # 125 BUILDING #5
Mailing Address - City:INDPLS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-1364
Mailing Address - Country:US
Mailing Address - Phone:317-541-9159
Mailing Address - Fax:317-541-9179
Practice Address - Street 1:5670 CAITO DR
Practice Address - Street 2:SUITE # 125 BUILDING #5
Practice Address - City:INDPLS
Practice Address - State:IN
Practice Address - Zip Code:46226-1364
Practice Address - Country:US
Practice Address - Phone:317-541-9159
Practice Address - Fax:317-541-9179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-27
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029502A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200930000AMedicaid
IN100235680Medicaid
IND70780Medicare UPIN
IN100235680Medicaid