Provider Demographics
NPI:1558748129
Name:HEARN, DIANA DOMINGO (DO)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:DOMINGO
Last Name:HEARN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 CEDAR LN STE 207
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4312
Mailing Address - Country:US
Mailing Address - Phone:201-833-7087
Mailing Address - Fax:
Practice Address - Street 1:222 CEDAR LN STE 207
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4312
Practice Address - Country:US
Practice Address - Phone:201-833-7087
Practice Address - Fax:201-833-7123
Is Sole Proprietor?:No
Enumeration Date:2015-05-02
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MB10082700207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0739324Medicaid