Provider Demographics
NPI:1093780827
Name:CALDERON-VILLANUEVA, DIANE E (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:E
Last Name:CALDERON-VILLANUEVA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6254 97TH PL
Mailing Address - Street 2:APT 8E
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1346
Mailing Address - Country:US
Mailing Address - Phone:917-553-2541
Mailing Address - Fax:
Practice Address - Street 1:33 W 42ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-8005
Practice Address - Country:US
Practice Address - Phone:212-389-4001
Practice Address - Fax:212-938-5831
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3876152W00000X
NYTUV 006768-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03231078Medicaid
FL620967000Medicaid
FL620967000Medicaid