Provider Demographics
NPI:1235491226
Name:DIDIANO, DEANNA MARIE (DO)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:MARIE
Last Name:DIDIANO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1585 FORNEY CREEK PKWY
Practice Address - Street 2:STE 2100
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-9514
Practice Address - Country:US
Practice Address - Phone:704-489-0365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01351207QS0010X, 207RS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1235491226Medicaid
NCNCT524AMedicare PIN
NC1235491226Medicaid