Provider Demographics
NPI:1992848774
Name:GONZALES, DIANE FRIDLEY (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:FRIDLEY
Last Name:GONZALES
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 1:1525 MYRTLE PL
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-2537
Mailing Address - Country:US
Mailing Address - Phone:337-261-3198
Mailing Address - Fax:
Practice Address - Street 1:220 S MARKET ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-5140
Practice Address - Country:US
Practice Address - Phone:337-948-0226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09806R2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1695360Medicaid
LAF89077Medicare UPIN