Provider Demographics
NPI:1902868490
Name:THALER, DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:THALER
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-683-5278
Mailing Address - Fax:920-686-9674
Practice Address - Street 1:33 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-2831
Practice Address - Country:US
Practice Address - Phone:920-683-5278
Practice Address - Fax:920-686-9674
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23517020174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI001117140OtherMEDICARE
WI23517-020OtherSTATE LICENSE
WIAT2558306OtherDEA
WI30773600Medicaid
WIP00392943OtherRAILROAD MEDICARE
WIB57101Medicare UPIN