Provider Demographics
NPI:1629024922
Name:ROMAN, DIANA
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 EVERGREEN PLACE
Mailing Address - Street 2:701
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018
Mailing Address - Country:US
Mailing Address - Phone:973-395-3701
Mailing Address - Fax:732-247-1124
Practice Address - Street 1:46 BAYARD ST
Practice Address - Street 2:SUITE 405
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-2152
Practice Address - Country:US
Practice Address - Phone:732-247-1106
Practice Address - Fax:732-247-1124
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0601860207R00000X
NJ25MA07628900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ116427OtherMEDICARE PROVIDER
NJ0107140Medicaid