Provider Demographics
NPI:1831267590
Name:CASANOVA, DIANA (MD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:CASANOVA
Suffix:
Gender:F
Credentials:MD
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 13030
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79768
Mailing Address - Country:US
Mailing Address - Phone:432-332-1273
Mailing Address - Fax:432-367-8687
Practice Address - Street 1:601 E 2ND ST
Practice Address - Street 2:SUITE F
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5423
Practice Address - Country:US
Practice Address - Phone:432-332-1273
Practice Address - Fax:432-367-8687
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8798207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148739901Medicaid
TX148739901Medicaid
TX8F8340Medicare PIN
TX148739901Medicaid