Provider Demographics
NPI:1861673758
Name:HAM, DIANA S
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:S
Last Name:HAM
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 1:5622 218TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1914
Mailing Address - Country:US
Mailing Address - Phone:917-330-5474
Mailing Address - Fax:718-886-5823
Practice Address - Street 1:14429 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4230
Practice Address - Country:US
Practice Address - Phone:718-886-1515
Practice Address - Fax:718-886-5823
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01562418Medicaid