Basic Information
Provider Information | |||||||||
NPI: | 1376530527 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIANA | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DIANA | ||||||||
OtherFirstName: | RICHARD | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: | I | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2408 WHITNEY AVE | ||||||||
Address2: |   | ||||||||
City: | HAMDEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065183209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2036260160 | ||||||||
FaxNumber: | 2032946734 | ||||||||
Practice Location | |||||||||
Address1: | 2408 WHITNEY AVE | ||||||||
Address2: |   | ||||||||
City: | HAMDEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065183209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2034073540 | ||||||||
FaxNumber: | 2034668590 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2005 | ||||||||
LastUpdateDate: | 07/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 032773 | CT | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0005X | 32773 | CT | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 32773 | CT | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.