Provider Demographics
NPI:1346745395
Name:TYRELL-SMITH, DIAMOND
Entity Type:Individual
Prefix:
First Name:DIAMOND
Middle Name:
Last Name:TYRELL-SMITH
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 1:858 NEW BRITAIN AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3919
Mailing Address - Country:US
Mailing Address - Phone:860-538-8942
Mailing Address - Fax:
Practice Address - Street 1:130 HARTFORD RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-5921
Practice Address - Country:US
Practice Address - Phone:860-538-8942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT048167788207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine