Provider Demographics
NPI:1104889294
Name:ELMORE, DIANE L (MD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:ELMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 N DOBSON RD STE 108
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5278
Mailing Address - Country:US
Mailing Address - Phone:480-456-9300
Mailing Address - Fax:
Practice Address - Street 1:450 N DOBSON RD STE 108
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5278
Practice Address - Country:US
Practice Address - Phone:480-456-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17601207PH0002X, 207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWMBFG03Medicare PIN
AZE59825Medicare UPIN