Provider Demographics
NPI:1932316114
Name:MATER, DIANE MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARIE
Last Name:MATER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3955 PATIENT CARE WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-4299
Mailing Address - Country:US
Mailing Address - Phone:517-374-7600
Mailing Address - Fax:517-374-9042
Practice Address - Street 1:840 E MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3293
Practice Address - Country:US
Practice Address - Phone:517-853-3704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017172207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI853303755OtherBCBS PIN
MI9836558OtherAETNA ID
MI1932316114Medicaid
MI853303755OtherBCBS PIN