Provider Demographics
NPI:1750619821
Name:MARTIN, DIANNA J
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 W T C JESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-3200
Mailing Address - Country:US
Mailing Address - Phone:713-864-5196
Mailing Address - Fax:713-864-4839
Practice Address - Street 1:1770 W T C JESTER BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-3200
Practice Address - Country:US
Practice Address - Phone:713-864-5196
Practice Address - Fax:713-864-4839
Is Sole Proprietor?:No
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41257183500000X
MSE-09501183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist