Healthcare Provider Details

I. General information

NPI: 1053378034
Provider Name (Legal Business Name): DIANE ALICE CULIK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2644 FLORLEN AVE NE
GRAND RAPIDS MI
49525-3968
US

IV. Provider business mailing address

2644 FLORLEN AVE NE
GRAND RAPIDS MI
49525-3968
US

V. Phone/Fax

Practice location:
  • Phone: 855-669-9355
  • Fax: 888-480-3870
Mailing address:
  • Phone: 313-443-1306
  • Fax: 888-480-3870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number038399
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: