Provider Demographics
NPI:1205942158
Name:PITTMAN, DIANE MOUNTAIN (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MOUNTAIN
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:514 BELTRAMI AVE NW
Mailing Address - Street 2:STE 102
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3010
Mailing Address - Country:US
Mailing Address - Phone:218-308-0294
Mailing Address - Fax:888-375-3627
Practice Address - Street 1:521 MINNESOTA AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3024
Practice Address - Country:US
Practice Address - Phone:218-308-0294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0296377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN966553600Medicaid
MN966553600Medicaid
MN930003771Medicare PIN