Provider Demographics
NPI:1609280502
Name:MANIEV, DIANA (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MANIEV
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 1:1000 E ROLLINS RD
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-2228
Mailing Address - Country:US
Mailing Address - Phone:847-367-5400
Mailing Address - Fax:
Practice Address - Street 1:1000 E ROLLINS RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-2228
Practice Address - Country:US
Practice Address - Phone:847-367-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105918390200000X
IL036.142736208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program