Provider Demographics
NPI:1154687945
Name:STEPHENS, DIANA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:STEPHENS
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 1:1020 CRAFT RD STE A
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1016
Mailing Address - Country:US
Mailing Address - Phone:607-339-0456
Mailing Address - Fax:
Practice Address - Street 1:1020 CRAFT RD STE A
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1016
Practice Address - Country:US
Practice Address - Phone:607-339-0456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2018-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294045207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology