Healthcare Provider Details

I. General information

NPI: 1891933032
Provider Name (Legal Business Name): DIANNE MARTIN MD PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2009
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5670 CAITO DR SUITE # 125 BUILDING #5
INDPLS IN
46226-1364
US

IV. Provider business mailing address

5670 CAITO DR SUITE # 125 BUILDING #5
INDPLS IN
46226-1364
US

V. Phone/Fax

Practice location:
  • Phone: 317-541-9159
  • Fax: 317-541-9179
Mailing address:
  • Phone: 317-541-9159
  • Fax: 317-541-9179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01029502A
License Number StateIN

VIII. Authorized Official

Name: DR. DIANNE MARTIN
Title or Position: MD/PSYCHIATRIST
Credential: MD
Phone: 317-541-9154