Provider Demographics
NPI:1659553766
Name:FORD, DIANE S (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:S
Last Name:FORD
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:PO BOX 1924
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-0924
Mailing Address - Country:US
Mailing Address - Phone:301-694-5292
Mailing Address - Fax:301-694-2319
Practice Address - Street 1:68 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE C
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4300
Practice Address - Country:US
Practice Address - Phone:301-694-5292
Practice Address - Fax:301-694-2319
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0040701207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD279M376FMedicare PIN