Provider Demographics
NPI:1255423539
Name:HLAVACEK, DIANE ELIZABETH (MD)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ELIZABETH
Last Name:HLAVACEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:ELIZABETH
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:16641 N 40TH STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3343
Mailing Address - Country:US
Mailing Address - Phone:602-482-2929
Mailing Address - Fax:602-482-4976
Practice Address - Street 1:16641 N 40TH STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3343
Practice Address - Country:US
Practice Address - Phone:602-482-2929
Practice Address - Fax:602-482-4976
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ31335207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ788169Medicaid
76115Medicare ID - Type Unspecified
H93468Medicare UPIN