Provider Demographics
NPI:1699717322
Name:DIENER, BRIAN CRAIG (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:CRAIG
Last Name:DIENER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 S JACKSON AVE STE 505
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-9060
Mailing Address - Country:US
Mailing Address - Phone:918-747-5322
Mailing Address - Fax:918-746-7604
Practice Address - Street 1:802 S JACKSON AVE STE 505
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9060
Practice Address - Country:US
Practice Address - Phone:918-747-5322
Practice Address - Fax:918-746-7604
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3943208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200086360AMedicaid
OK246635308Medicare PIN