Provider Demographics
NPI:1740350776
Name:GOLDWATER, DIANE L (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:L
Last Name:GOLDWATER
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2647
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32004-2647
Mailing Address - Country:US
Mailing Address - Phone:310-535-1778
Mailing Address - Fax:
Practice Address - Street 1:830 A1A NORTH SUITE 13
Practice Address - Street 2:#105
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082
Practice Address - Country:US
Practice Address - Phone:310-535-1778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63438207P00000X
TXH4354207P00000X
CAA0450372083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23680Medicare ID - Type Unspecified
FLE93658Medicare UPIN