Provider Demographics
NPI:1710993845
Name:WALLACE, DIANA RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:RENEE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 TURIN ROAD
Mailing Address - Street 2:BUILDING 4, SUITE 2
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-7423
Mailing Address - Country:US
Mailing Address - Phone:315-338-7284
Mailing Address - Fax:315-338-7286
Practice Address - Street 1:7900 TURIN ROAD
Practice Address - Street 2:BUILDING 4, SUITE 2
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-7423
Practice Address - Country:US
Practice Address - Phone:315-338-7284
Practice Address - Fax:315-338-7286
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 433457207V00000X
NY255422207V00000X
NMMD 2015-0031207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2039121OtherHIGHMARK BLUE SHIELD
PA212422OtherJOHNS HOPKINS
PA118476OtherGEISINGER HEALTH PLAN
PA1572573OtherGATEWAY-WMG
MD932354OtherCAREFIRST MD BCBS
PA50077199OtherCAPITAL BLUE CROSS-WMG
PA92199182OtherAETNA
PA20076171OtherAMERIHEALTH MERCY-WMG
PA212422OtherJOHNS HOPKINS