Provider Demographics
NPI:1003893322
Name:SMITH, DIANE E (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 HOSPITAL DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-5009
Mailing Address - Country:US
Mailing Address - Phone:802-447-5519
Mailing Address - Fax:802-447-5657
Practice Address - Street 1:100 KENYON AVE
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4216
Practice Address - Country:US
Practice Address - Phone:401-782-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042212207R00000X
VT0420013392207R00000X
RIMD09423207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1026765Medicaid
RIU400473648OtherMEDICARE
VT1026765Medicaid