Provider Demographics
NPI:1508839077
Name:FERTSCH, DIANA (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:FERTSCH
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1792 MERRITT BLVD
Mailing Address - Street 2:DUNDALK PEDIATRIC ASSOCIATES
Mailing Address - City:DUNDALK
Mailing Address - State:MD
Mailing Address - Zip Code:21222
Mailing Address - Country:US
Mailing Address - Phone:410-284-1133
Mailing Address - Fax:410-284-3371
Practice Address - Street 1:1792 MERRITT BLVD
Practice Address - Street 2:DUNDALK PEDIATRIC ASSOCIATES
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-2122
Practice Address - Country:US
Practice Address - Phone:410-284-1133
Practice Address - Fax:410-284-3371
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD45937208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD147571100Medicaid