Provider Demographics
NPI:1235347576
Name:VERDE, DIANA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:VERDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:LYNN
Other - Last Name:VERDE-DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:W14302 BROOKWOOD CT
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:WI
Mailing Address - Zip Code:54971-9533
Mailing Address - Country:US
Mailing Address - Phone:602-663-0044
Mailing Address - Fax:920-346-5900
Practice Address - Street 1:649 W OSHKOSH ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-1040
Practice Address - Country:US
Practice Address - Phone:920-745-2282
Practice Address - Fax:920-745-2280
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34295-022084P0015X
CAC535752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31956700Medicaid
WIF65664Medicare UPIN