Provider Demographics
NPI:1942274709
Name:DIACOVO, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:DIACOVO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-3518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:COLUMBIA UNIVERSITY DEPARTMENT PEDIATRICS
Practice Address - Street 2:3959 BROADWAY
Practice Address - City:NEW YOR
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-927-3214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2343082080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02635927Medicaid
NY02635927Medicaid
NY628Y41Medicare ID - Type Unspecified