Provider Demographics
NPI:1275980450
Name:ATHONVARANGKUL, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:ATHONVARANGKUL
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 1:15 YORK ST
Mailing Address - Street 2:YNHH DEPT OF MEDICINE, LMP 1092
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3221
Mailing Address - Country:US
Mailing Address - Phone:203-688-5555
Mailing Address - Fax:
Practice Address - Street 1:15 YORK ST
Practice Address - Street 2:YNHH DEPT OF MEDICINE, LMP 1092
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3221
Practice Address - Country:US
Practice Address - Phone:203-688-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT69446207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program