Provider Demographics
NPI:1386735710
Name:DOERSAM, DIANE WALLING (RPH)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:WALLING
Last Name:DOERSAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 MERTON MINTER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4404
Mailing Address - Country:US
Mailing Address - Phone:210-617-5300
Mailing Address - Fax:210-949-3595
Practice Address - Street 1:7400 MERTON MINTER ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4404
Practice Address - Country:US
Practice Address - Phone:210-617-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24140183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist