Provider Demographics
NPI:1558419440
Name:BRANKS, DIANE D (DPM)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:D
Last Name:BRANKS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:D
Other - Last Name:BRANKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:1011 BALDWIN PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-5806
Mailing Address - Country:US
Mailing Address - Phone:626-851-1011
Mailing Address - Fax:
Practice Address - Street 1:1011 BALDWIN PARK BLVD
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-5806
Practice Address - Country:US
Practice Address - Phone:626-851-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3425213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWE3425AMedicare UPIN