Healthcare Provider Details

I. General information

NPI: 1356308852
Provider Name (Legal Business Name): DIANNE KOWING O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 NATIONAL HEALTH CARE DR
DAYTONA BEACH FL
32114-1495
US

IV. Provider business mailing address

1517 N HALIFAX AVE
DAYTONA BEACH FL
32118-3519
US

V. Phone/Fax

Practice location:
  • Phone: 386-323-7500
  • Fax: 386-323-7564
Mailing address:
  • Phone: 386-248-3260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 2067
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP1000070
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: