Provider Demographics
NPI:1205010790
Name:KINSELLA, MARY DIANE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DIANE
Last Name:KINSELLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:DIANE
Other - Last Name:DARROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:1412 MILSTEAD AVE NE DEPT OF
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012
Practice Address - Country:US
Practice Address - Phone:678-423-1550
Practice Address - Fax:678-423-1550
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002586207ZP0102X
GA64527207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology