MEDICARE: DR. DIANE KLIVINGTON DO, MS

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	207V00000X	Obstetrics & Gynecology Physician	21472	MS
2	207V00000X	Obstetrics & Gynecology Physician	1313	HI
3	207V00000X	Obstetrics & Gynecology Physician	2094	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407990740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE KLIVINGTON DO, MS

Provider Business Mailing Address
First Line	:	104 MEDICAL DR
Second Line	:
City	:	DOTHAN
State	:	AL
Zip	:	36303-6902
Country	:	US
Telephone Number	:	850-333-5113
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 MEDICAL DR
Second Line	:
City	:	DOTHAN
State	:	AL
Zip	:	36303-6902
Country	:	US
Telephone Number	:	850-333-5113
Fax Number	:

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

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	12/08/2020

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