Provider Demographics
NPI:1962445684
Name:DIANA, MARY G (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:G
Last Name:DIANA
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 GEORGETOWN N
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06831-5235
Mailing Address - Country:US
Mailing Address - Phone:845-325-6127
Mailing Address - Fax:
Practice Address - Street 1:12 AVERY PLACE
Practice Address - Street 2:AVERY CENTER FOR OBSTETRICS & GYNECOLOGY
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880
Practice Address - Country:US
Practice Address - Phone:203-227-5125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT56749207V00000X
NY200058207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0667910001OtherDME
NY01659383Medicaid
NYP00413156OtherMEDICARE RAILROAD
NY32G301Medicare PIN
NY01659383Medicaid