Provider Demographics
NPI:1578663084
Name:FABRICIUS, DIANE LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:LOUISE
Last Name:FABRICIUS
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 1:653 BRIARCLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-8799
Mailing Address - Country:US
Mailing Address - Phone:865-482-6080
Mailing Address - Fax:865-482-4070
Practice Address - Street 1:653 BRIARCLIFF AVE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-8799
Practice Address - Country:US
Practice Address - Phone:865-482-6080
Practice Address - Fax:865-482-4070
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000030687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3836002Medicaid
TN3836002Medicaid
TNC46215Medicare UPIN