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1235237074

NPI Code Detail

MEDICARE: DR. DIANE MARIE HENTZ M.D.

MEDICARE: DR. DIANE MARIE HENTZ M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	01038843A	IN
2	207NS0135X	Procedural Dermatology Physician	01038843A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00074720	OTHER		MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	01038843B	OTHER	IN	CSR LICENSE NUMBER
3	1390	OTHER		PHP
4	000000308077	OTHER		BCBS
5	4045038	OTHER		AETNA
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235237074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE MARIE HENTZ M.D.

Provider Business Mailing Address
First Line	:	5750 FALLS DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7147
Country	:	US
Telephone Number	:	260-436-8000
Fax Number	:	260-432-5587

Provider Business Practice Location Address
First Line	:	5750 FALLS DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7147
Country	:	US
Telephone Number	:	260-436-8000
Fax Number	:	260-432-5587

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	03/07/2023

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1194823989 — MS. PAMELA SUE SHODA N.P.
Practice Location Address:

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Practice Location Address:

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46804-7147

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1407956923 — DR. JAMES RICHARD KYLER M.D.
Practice Location Address:

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Directions to “ DR. DIANE MARIE HENTZ M.D.” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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