Provider Demographics
NPI:1184655078
Name:BERSON, DIANE S
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:S
Last Name:BERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E 53RD ST
Mailing Address - Street 2:STE 3
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4803
Mailing Address - Country:US
Mailing Address - Phone:212-355-3511
Mailing Address - Fax:212-355-3552
Practice Address - Street 1:211 E 53RD ST
Practice Address - Street 2:STE 3
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-4803
Practice Address - Country:US
Practice Address - Phone:212-355-3511
Practice Address - Fax:212-355-3552
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166776207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY17F311Medicare ID - Type Unspecified
NYD92021Medicare UPIN