Basic Information
Provider Information | |||||||||
NPI: | 1538330352 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIAGNE | ||||||||
FirstName: | THIENDELLA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4422 S MCCOLL RD | ||||||||
Address2: |   | ||||||||
City: | EDINBURG | ||||||||
State: | TX | ||||||||
PostalCode: | 785399608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9568004378 | ||||||||
FaxNumber: | 9568004378 | ||||||||
Practice Location | |||||||||
Address1: | 4422 S MCCOLL RD | ||||||||
Address2: |   | ||||||||
City: | EDINBURG | ||||||||
State: | TX | ||||||||
PostalCode: | 785399608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9568004378 | ||||||||
FaxNumber: | 9568004379 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2008 | ||||||||
LastUpdateDate: | 12/25/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | P0196 | TX | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 286734301 | 05 | TX |   | MEDICAID | 8CY579 | 01 | TX | BCBS TX | OTHER |