Provider Demographics
NPI:1598794711
Name:BOURLIER, DIANE (DO)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BOURLIER
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:PO BOX 10030
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-0030
Mailing Address - Country:US
Mailing Address - Phone:386-274-7800
Mailing Address - Fax:386-274-7801
Practice Address - Street 1:3001 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-870-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7987207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL49154OtherBLUE CROSS OF FLORIDA
FL257467500Medicaid
FL225207OtherAMERIGROUP
FLG13693Medicare UPIN
FL49154ZMedicare PIN
FL49154YMedicare PIN