Provider Demographics
NPI:1073212510
Name:MATERA, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MATERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 TENAFLY PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-4032
Mailing Address - Country:US
Mailing Address - Phone:718-619-9721
Mailing Address - Fax:
Practice Address - Street 1:58 TENAFLY PL
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-4032
Practice Address - Country:US
Practice Address - Phone:718-619-9721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist