Provider Demographics
NPI:1003897398
Name:MACDONNELL, DIANE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARIE
Last Name:MACDONNELL
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 1:461 GLEN ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-2906
Mailing Address - Country:US
Mailing Address - Phone:518-745-5889
Mailing Address - Fax:518-745-0010
Practice Address - Street 1:461 GLEN ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-2906
Practice Address - Country:US
Practice Address - Phone:518-745-5889
Practice Address - Fax:518-745-0010
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172673-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF20251Medicare UPIN
NY55487BMedicare ID - Type Unspecified