Provider Demographics
NPI:1164574778
Name:MICKLEY, DIANE WILKINS (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:WILKINS
Last Name:MICKLEY
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 1:7 RIVERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06831-3627
Mailing Address - Country:US
Mailing Address - Phone:203-531-1909
Mailing Address - Fax:203-531-7449
Practice Address - Street 1:7 RIVERSVILLE RD
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831-3627
Practice Address - Country:US
Practice Address - Phone:203-531-1909
Practice Address - Fax:203-531-7449
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT16643207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine