Provider Demographics
NPI:1790784973
Name:FURY, DIANNA LYNNE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANNA
Middle Name:LYNNE
Last Name:FURY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 SANDIA LOOP
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-7076
Mailing Address - Country:US
Mailing Address - Phone:505-867-4696
Mailing Address - Fax:505-867-4997
Practice Address - Street 1:203 SANDIA DAY SCHOOL ROAD
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004
Practice Address - Country:US
Practice Address - Phone:505-867-4696
Practice Address - Fax:505-867-4997
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30414207Q00000X
NMMD2011-0163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM07235551Medicaid
NM330546YR41Medicare PIN
CO01304146Medicaid