Basic Information
| Provider Information | |||||||||
| NPI: | 1225002165 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STULC | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | MINASIAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5410 MARYLAND WAY 300 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370725064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153775658 | ||||||||
| FaxNumber: | 8882411404 | ||||||||
| Practice Location | |||||||||
| Address1: | 969 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153775658 | ||||||||
| FaxNumber: | 8882411404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 12/21/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20783 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 36090 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01139543 | 05 | MS | MEDICAID | 64024268 | 05 | KY | MEDICAID |