Provider Demographics
NPI:1174537047
Name:BOLDUC, DIANE (MD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BOLDUC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 MEDICAL LOOP
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1645
Mailing Address - Country:US
Mailing Address - Phone:541-464-5907
Mailing Address - Fax:541-464-8481
Practice Address - Street 1:340 MEDICAL LOOP
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1645
Practice Address - Country:US
Practice Address - Phone:541-464-5907
Practice Address - Fax:541-464-8481
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287185Medicaid
OR840254000OtherREGENCE BLUE CROSS
ORJ103601OtherPACIFIC SOURCE
32945700000OtherPROVIDENCE HEALTH PLANS
608828900OtherBLACK LUNG FEDERAL PROGRA
OR119657Medicare PIN
OR840254000OtherREGENCE BLUE CROSS
PINP00173518Medicare ID - Type UnspecifiedRAILROAD MEDICARE