Provider Demographics
NPI:1639123912
Name:DIANA, CHARLES L (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:DIANA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 LEWIS BAY RD
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-5210
Mailing Address - Country:US
Mailing Address - Phone:508-862-7813
Mailing Address - Fax:774-552-6924
Practice Address - Street 1:66 LEWIS BAY RD
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-5210
Practice Address - Country:US
Practice Address - Phone:508-862-7813
Practice Address - Fax:774-552-6924
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0570332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3019314Medicaid
B98029Medicare UPIN
MAJ06558Medicare ID - Type Unspecified