Basic Information
| Provider Information | |||||||||
| NPI: | 1649208638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KECSKES | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 732 N RUSSELL AVE | ||||||||
| Address2: | |||||||||
| City: | CLOVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936110329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592896853 | ||||||||
| FaxNumber: | 5592992587 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 W CLINTON AVE BLDG A | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937054206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592647521 | ||||||||
| FaxNumber: | 5592330016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0005X | G074951 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurodevelopmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | G074951 | 05 | CA | MEDICAID |