Provider Demographics
NPI:1881686111
Name:BARDO, DIANNA ME (MD)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:ME
Last Name:BARDO
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 1:225 E CHICAGO AVE # 9
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-4500
Mailing Address - Fax:312-227-9784
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-1213
Practice Address - Fax:602-933-1214
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD279312085N0700X
IL0361023222085N0700X, 2085P0229X, 2085R0202X
WAMD605156352085N0700X, 2085R0202X
AZ509962085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ044185Medicaid
IL036102322Medicaid
WA1056261Medicaid
AZ044185Medicaid