Provider Demographics
NPI:1881600534
Name:ANDERSON, DIANE (DO)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DO
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 750243
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45475-0243
Mailing Address - Country:US
Mailing Address - Phone:937-709-5051
Mailing Address - Fax:937-709-5050
Practice Address - Street 1:3130 N COUNTY ROAD 25A
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:937-440-4786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH340053282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2364838Medicaid
OHCK1297OtherRAILROAD MEDICARE
300132256OtherRAILROAD MEDICARE
300132256OtherRAILROAD MEDICARE
OH2364838Medicaid
OHAN0810072Medicare PIN
OHCK1297OtherRAILROAD MEDICARE
0810073Medicare PIN