Provider Demographics
NPI:1790046837
Name:POLLACK, DIANA A
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:A
Last Name:POLLACK
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 1:514 KNOLL CT
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-1119
Mailing Address - Country:US
Mailing Address - Phone:516-342-9719
Mailing Address - Fax:
Practice Address - Street 1:514 KNOLL CT
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1119
Practice Address - Country:US
Practice Address - Phone:516-342-9719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1767827174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist