Healthcare Provider Details

I. General information

NPI: 1508842311
Provider Name (Legal Business Name): DIANE M ICENOGLE LEUSCHEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 MERTON MINTER
SAN ANTONIO TX
78229-4404
US

IV. Provider business mailing address

7400 MERTON MINTER
SAN ANTONIO TX
78229-4404
US

V. Phone/Fax

Practice location:
  • Phone: 210-617-5300
  • Fax: 210-949-3350
Mailing address:
  • Phone: 210-617-5300
  • Fax: 210-949-3350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberJ8600
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: