Healthcare Provider Details

I. General information

NPI: 1932316114
Provider Name (Legal Business Name): DIANE MARIE MATER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 E MOUNT HOPE AVE
LANSING MI
48910-3293
US

IV. Provider business mailing address

3955 PATIENT CARE WAY SUITE A
LANSING MI
48911-4299
US

V. Phone/Fax

Practice location:
  • Phone: 517-853-3704
  • Fax:
Mailing address:
  • Phone: 517-374-7600
  • Fax: 517-374-9042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101017172
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: