Healthcare Provider Details

I. General information

NPI: 1245566181
Provider Name (Legal Business Name): DIANNE ELIZABETH ADAMS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANNE ELIZABETH WATSON DO

II. Dates (important events)

Enumeration Date: 10/28/2009
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 LEXINGTON AVE
LAWRENCEVILLE IL
62439-2085
US

IV. Provider business mailing address

2111 LEXINGTON AVE
LAWRENCEVILLE IL
62439-2085
US

V. Phone/Fax

Practice location:
  • Phone: 618-943-7421
  • Fax:
Mailing address:
  • Phone: 618-943-7421
  • Fax: 907-733-1735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5006
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number03569
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number169535
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number5006
License Number StateOK
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.163171
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: