Provider Demographics
NPI:1871028316
Name:VORK, DIANA LEIGH
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LEIGH
Last Name:VORK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:LEIGH
Other - Last Name:DALRYMPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:1191 FORTUNE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7474
Practice Address - Country:US
Practice Address - Phone:618-622-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-21
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN64202207N00000X
IL036156222207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology