Provider Demographics
NPI:1104803253
Name:CERUZZI, DIANE M (DO)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:CERUZZI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10026 OLD OCEAN CITY BLVD
Mailing Address - Street 2:BUILDING ONE
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1288
Mailing Address - Country:US
Mailing Address - Phone:410-957-6622
Mailing Address - Fax:410-957-1229
Practice Address - Street 1:500 MARKET STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:POCOMOKE
Practice Address - State:MD
Practice Address - Zip Code:21851-1170
Practice Address - Country:US
Practice Address - Phone:410-957-6622
Practice Address - Fax:410-957-1229
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007477207Q00000X
MDH70020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD173486YR5OtherMEDICARE UNSPECIFIED
MD027366000Medicaid
DE1104803253Medicaid
4060563Medicare ID - Type Unspecified
MD027366000Medicaid