Healthcare Provider Details

I. General information

NPI: 1588689541
Provider Name (Legal Business Name): DIANA A. PRABLEK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA ALICIA MEDEROS MD

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3824 S GRAND BLVD
SAINT LOUIS MO
63118-3412
US

IV. Provider business mailing address

850 DEAVER LN
SAINT LOUIS MO
63141-7732
US

V. Phone/Fax

Practice location:
  • Phone: 314-814-8180
  • Fax: 314-814-8188
Mailing address:
  • Phone: 314-941-4896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number109302
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number109302
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: