Provider Demographics
NPI:1588689541
Name:PRABLEK, DIANA A (MD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:A
Last Name:PRABLEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:ALICIA
Other - Last Name:MEDEROS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:850 DEAVER LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7732
Mailing Address - Country:US
Mailing Address - Phone:314-941-4896
Mailing Address - Fax:
Practice Address - Street 1:4055 VALLEY VIEW LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-5074
Practice Address - Country:US
Practice Address - Phone:469-466-7420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109302207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208051730Medicaid
MO208051730Medicaid
931864694Medicare PIN
MO208051730Medicaid