Provider Demographics
NPI:1649372004
Name:MAHONEY, DIANNA LYNN (MD)
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:LYNN
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANNA
Other - Middle Name:LYNN
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:928-338-3522
Practice Address - Street 1:200 W. HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941-0860
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:928-338-3522
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2008-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27347207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ618514Medicaid
AZ1629236716Medicaid
AZ1780614008Medicaid
AZ1871523191Medicaid
AZ1295993376Medicaid
AZ1629236716Medicaid
AZH11276Medicare UPIN
AZ1780614008Medicaid