Provider Demographics
NPI:1679835607
Name:WHITE, DIAN
Entity Type:Individual
Prefix:MRS
First Name:DIAN
Middle Name:
Last Name:WHITE
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 1:4068 EDSON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-2244
Mailing Address - Country:US
Mailing Address - Phone:347-202-9535
Mailing Address - Fax:
Practice Address - Street 1:4068 EDSON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-2244
Practice Address - Country:US
Practice Address - Phone:347-202-9535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist