Basic Information
| Provider Information | |||||||||
| NPI: | 1629173166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUCKWORTH | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 COUNTY RD 120 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563034813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202028949 | ||||||||
| FaxNumber: | 3202020756 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 33RD ST S | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563019668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202518181 | ||||||||
| FaxNumber: | 3202516942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 11/23/2010 | ||||||||
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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 | 207V00000X | 46347 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 659457300 | 05 | MN | MEDICAID |