Provider Demographics
NPI:1568423754
Name:GUADARA, DIANE (DPM)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GUADARA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601
Mailing Address - Country:US
Mailing Address - Phone:201-488-8599
Mailing Address - Fax:201-488-4953
Practice Address - Street 1:835 MAIN ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601
Practice Address - Country:US
Practice Address - Phone:201-488-8599
Practice Address - Fax:201-488-4953
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD2455213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7695101Medicaid
NJ696791Medicare ID - Type Unspecified
NJ7695101Medicaid