Provider Demographics
NPI:1437162898
Name:DEMALLIE, DIANE ALICE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:ALICE
Last Name:DEMALLIE
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 1:2213 N NEVADA AVE
Mailing Address - Street 2:# 215
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6801
Mailing Address - Country:US
Mailing Address - Phone:719-572-6266
Mailing Address - Fax:
Practice Address - Street 1:2864 S CIRCLE DR STE 500
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4123
Practice Address - Country:US
Practice Address - Phone:719-473-2346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO411022084P0800X
CAA559822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F96681Medicare UPIN
804981Medicare ID - Type Unspecified