Provider Demographics
NPI:1376507301
Name:FOUNTAS, DIANE LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:LOUISE
Last Name:FOUNTAS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1389 W MAIN ST
Mailing Address - Street 2:SUITE 325
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3104
Mailing Address - Country:US
Mailing Address - Phone:203-753-6776
Mailing Address - Fax:203-573-1875
Practice Address - Street 1:1389 W MAIN ST
Practice Address - Street 2:SUITE 325
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3104
Practice Address - Country:US
Practice Address - Phone:203-753-6776
Practice Address - Fax:203-573-1875
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT0244362080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD83642Medicare UPIN