Provider Demographics
NPI:1639211188
Name:VALLECILLA LUKAUSKIS, DIANA MARIA (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIA
Last Name:VALLECILLA LUKAUSKIS
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 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:330 TURNER MCCALL BLVD SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5630
Practice Address - Country:US
Practice Address - Phone:706-291-1754
Practice Address - Fax:706-291-2227
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058590207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA873915717BMedicaid
GA511I160144Medicare PIN