Provider Demographics
NPI:1730183450
Name:PFEIFER, DIANE M (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:M
Last Name:PFEIFER
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 1:2350 S DIXON RD
Mailing Address - Street 2:STE 400
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-6420
Mailing Address - Country:US
Mailing Address - Phone:765-455-9801
Mailing Address - Fax:765-455-9840
Practice Address - Street 1:2350 S DIXON RD
Practice Address - Street 2:STE 400
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6420
Practice Address - Country:US
Practice Address - Phone:765-455-9801
Practice Address - Fax:765-455-9840
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050142174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2002234890AMedicaid
IN000000093486OtherBLUE CROSS
IN000000093486OtherBLUE CROSS
ING94992Medicare UPIN