Provider Demographics
NPI:1619957594
Name:FABERY, DIANE L (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:L
Last Name:FABERY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 SPARTA AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-1122
Mailing Address - Country:US
Mailing Address - Phone:973-729-9199
Mailing Address - Fax:
Practice Address - Street 1:270 SPARTA AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1122
Practice Address - Country:US
Practice Address - Phone:973-729-9199
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJOAO005365152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7166702Medicaid
NJ7166702Medicaid
796098Medicare ID - Type Unspecified