Healthcare Provider Details

I. General information

NPI: 1225002165
Provider Name (Legal Business Name): DIANA MINASIAN STULC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4606
US

IV. Provider business mailing address

5410 MARYLAND WAY 300
BRENTWOOD TN
37072-5064
US

V. Phone/Fax

Practice location:
  • Phone: 615-377-5658
  • Fax: 888-241-1404
Mailing address:
  • Phone: 615-377-5658
  • Fax: 888-241-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20783
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36090
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: