Provider Demographics
NPI:1568775104
Name:DIANALAN, JOHAIRA LIDASAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHAIRA
Middle Name:LIDASAN
Last Name:DIANALAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:55 WATER STREET
Mailing Address - Street 2:2ND FLOOR CRED DEPT
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:140-15 SANFORD AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355
Practice Address - Country:US
Practice Address - Phone:718-826-4000
Practice Address - Fax:718-826-4075
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-25
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY271857207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty