Provider Demographics
NPI:1285831289
Name:DINER, MARTIN DEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:DEAN
Last Name:DINER
Suffix:
Gender:M
Credentials:PHD
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 578
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963-0012
Mailing Address - Country:US
Mailing Address - Phone:631-725-2132
Mailing Address - Fax:631-237-4967
Practice Address - Street 1:1155C BRIDGEHAMPTON SAG HARBOR TURNPIKE
Practice Address - Street 2:
Practice Address - City:BRIDGEHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11932
Practice Address - Country:US
Practice Address - Phone:631-725-2132
Practice Address - Fax:631-237-4967
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011418103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY6665OtherINACTIVE LICENSE
NY011418OtherLICENSE
31149OtherNATIONAL REGISTER