Provider Demographics
NPI:1104810282
Name:LEVINE, DIANE R (RD, LD, CDE)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:R
Last Name:LEVINE
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:4002 KRESGE WAY
Practice Address - Street 2:SUITE 124
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4661
Practice Address - Country:US
Practice Address - Phone:502-895-4263
Practice Address - Fax:502-899-5488
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0635133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00000255836OtherANTHEM BC/BS PROVIDER NO.
KY710000497Medicare ID - Type UnspecifiedRAILROAD MEDICARE PROVIDE
KY0212108Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
KY1104810282Medicare PIN