Individual
DIANE JORDAN-WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1429 N 6TH ST, TERRE HAUTE, IN 47804-1037
(812) 232-0564
(812) 235-3330
Mailing address
221 S 6TH ST, TERRE HAUTE, IN 47807-4214
(812) 232-0564
(812) 235-3330
Taxonomy
Speciality
Code
Description
License number
State
207RA0201X
Allergy & Immunology (Internal Medicine) Physician
Primary
01056292A
IN
207RA0201X
Allergy & Immunology (Internal Medicine) Physician
36106006
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000230225
ANTHEM
—
01
—
030005377
RAILROAD MCARE PALAMETTO
—
05
—
200392780
—
IN
05
—
200392780Q
—
IN
01
—
P00844293
RAILROAD MEDICARE
IN
Enumeration date
08/29/2006
Last updated
03/14/2013
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