Healthcare Provider Details

I. General information

NPI: 1396903068
Provider Name (Legal Business Name): DIANNA PLYLER KUBACZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2290 W PRAIRIE AVE
COEUR D ALENE ID
83815-8424
US

IV. Provider business mailing address

2290 W PRAIRIE AVE
COEUR D ALENE ID
83815-8424
US

V. Phone/Fax

Practice location:
  • Phone: 208-772-7994
  • Fax: 208-772-5916
Mailing address:
  • Phone: 208-772-7994
  • Fax: 208-772-5916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number83623
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number3671970
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: