Provider Demographics
NPI:1114971140
Name:MCCORMICK, DIANE A (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:A
Last Name:MCCORMICK
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 1:6011 RENAISSANCE PL
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4720
Mailing Address - Country:US
Mailing Address - Phone:419-885-5929
Mailing Address - Fax:419-824-6436
Practice Address - Street 1:6011 RENAISSANCE PL
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4720
Practice Address - Country:US
Practice Address - Phone:419-885-5929
Practice Address - Fax:419-824-6436
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055529207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0785217Medicaid
OH35055529Medicare ID - Type Unspecified
OHE97368Medicare UPIN