Provider Demographics
NPI:1386674943
Name:MOCK, DIANA S (DO)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:S
Last Name:MOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 NICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9771
Mailing Address - Country:US
Mailing Address - Phone:509-429-5121
Mailing Address - Fax:
Practice Address - Street 1:105 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9771
Practice Address - Country:US
Practice Address - Phone:509-429-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO14182207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E95249Medicare UPIN