Provider Demographics
NPI:1487765483
Name:WEIS BONTKE, DIANE MARILYN (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARILYN
Last Name:WEIS BONTKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1314 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-1106
Mailing Address - Country:US
Mailing Address - Phone:217-522-9730
Mailing Address - Fax:217-522-9761
Practice Address - Street 1:700 NTH 7TH STREET
Practice Address - Street 2:STE C
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-522-9730
Practice Address - Fax:217-522-9761
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36104833207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine