Provider Demographics
NPI:1982831939
Name:DIAMOND, ALPHONSUS G (MD)
Entity Type:Individual
Prefix:
First Name:ALPHONSUS
Middle Name:G
Last Name:DIAMOND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:810 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-8201
Practice Address - Country:US
Practice Address - Phone:574-583-6543
Practice Address - Fax:574-583-9502
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068613A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000774056OtherANTHEM PROVIDER NUMBER
IN201018230Medicaid
IN201018230Medicaid
IN000000774056OtherANTHEM PROVIDER NUMBER