Provider Demographics
NPI:1508904103
Name:DIMOND, CAROL (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:DIMOND
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 1:2445 STATE ROUTE 30
Mailing Address - Street 2:SUNMOUNT DDSO
Mailing Address - City:TUPPER LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12986-2502
Mailing Address - Country:US
Mailing Address - Phone:518-359-7701
Mailing Address - Fax:518-359-4133
Practice Address - Street 1:2445 STATE ROUTE 30
Practice Address - Street 2:SUNMOUNT DDSO
Practice Address - City:TUPPER LAKE
Practice Address - State:NY
Practice Address - Zip Code:12986-2502
Practice Address - Country:US
Practice Address - Phone:518-359-7701
Practice Address - Fax:518-359-4133
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155797207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01183251Medicaid
NYE48839Medicare UPIN
NY01183251Medicaid