Provider Demographics
NPI:1073631081
Name:RICCIOLI, DIANA (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:RICCIOLI
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 1:230 E RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-4142
Mailing Address - Country:US
Mailing Address - Phone:201-967-4000
Mailing Address - Fax:
Practice Address - Street 1:925 CLIFTON AVE
Practice Address - Street 2:STE 103
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2724
Practice Address - Country:US
Practice Address - Phone:973-417-5256
Practice Address - Fax:973-471-5157
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA619082084B0040X
NJ25MA061908002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ820750Medicare ID - Type UnspecifiedPROVIDER
NJG11768Medicare UPIN