Provider Demographics
NPI:1063830370
Name:SHOLOMON, DIANNA (MD)
Entity Type:Individual
Prefix:MS
First Name:DIANNA
Middle Name:
Last Name:SHOLOMON
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 1:1379 54TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-4259
Mailing Address - Country:US
Mailing Address - Phone:718-436-1600
Mailing Address - Fax:718-436-2085
Practice Address - Street 1:1379 54TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-4259
Practice Address - Country:US
Practice Address - Phone:718-436-1600
Practice Address - Fax:718-436-2085
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY290069-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02559608Medicaid