Provider Demographics
NPI:1821006818
Name:TANENBAUM, DIANE GOLDBERG (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:GOLDBERG
Last Name:TANENBAUM
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 1:16 E 79TH ST
Mailing Address - Street 2:SUITE 22
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0150
Mailing Address - Country:US
Mailing Address - Phone:212-249-6122
Mailing Address - Fax:212-249-7838
Practice Address - Street 1:16 E 79TH ST
Practice Address - Street 2:SUITE 22
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0150
Practice Address - Country:US
Practice Address - Phone:212-249-6122
Practice Address - Fax:212-249-7838
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095197207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B16794Medicare UPIN
576081Medicare ID - Type Unspecified