Provider Demographics
NPI:1427194638
Name:TATE, DIANE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:TATE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6547 N AVONDALE AVE
Mailing Address - Street 2:SUITE 001
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1573
Mailing Address - Country:US
Mailing Address - Phone:773-775-1622
Mailing Address - Fax:773-775-1693
Practice Address - Street 1:6547 N AVONDALE AVE
Practice Address - Street 2:SUITE 001
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-1573
Practice Address - Country:US
Practice Address - Phone:773-775-1622
Practice Address - Fax:773-775-1693
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL11363Medicare UPIN
IL366690Medicare ID - Type Unspecified