Provider Demographics
NPI:1700829058
Name:KILDUFF, DIANE (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:KILDUFF
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 3652
Mailing Address - Street 2:8 WENAUMET BLUFF DR.
Mailing Address - City:POCASSET
Mailing Address - State:MA
Mailing Address - Zip Code:02559
Mailing Address - Country:US
Mailing Address - Phone:508-246-4463
Mailing Address - Fax:
Practice Address - Street 1:42 PATTON RD
Practice Address - Street 2:
Practice Address - City:AYER
Practice Address - State:MA
Practice Address - Zip Code:01434-3801
Practice Address - Country:US
Practice Address - Phone:978-796-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA198195207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0708216Medicaid
Q64029Medicare UPIN
MA0708216Medicaid