Provider Demographics
NPI:1689633216
Name:MAH, DIANA (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:MAH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DIANA
Other - Middle Name:MAH
Other - Last Name:SELF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:331 FISHEL RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-7449
Mailing Address - Country:US
Mailing Address - Phone:336-650-1091
Mailing Address - Fax:
Practice Address - Street 1:1601 BRENNER AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2515
Practice Address - Country:US
Practice Address - Phone:704-638-9000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1801152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist