Basic Information
| Provider Information | |||||||||
| NPI: | 1780845503 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | MOUSTOUKAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1514 JEFFERSON HWY | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701212429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048424000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1315 JEFFERSON HWY | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701212406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048423900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2008 | ||||||||
| LastUpdateDate: | 07/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | MD.205215 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2302451 | 05 | LA | MEDICAID | 00923576 | 05 | MS | MEDICAID |