Provider Demographics
NPI:1265439079
Name:PERRITANO, DIANE MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MICHELLE
Last Name:PERRITANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3066 E COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78220-1013
Mailing Address - Country:US
Mailing Address - Phone:210-233-7000
Mailing Address - Fax:210-277-6387
Practice Address - Street 1:311 CAMDEN ST
Practice Address - Street 2:STE. 601
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-2012
Practice Address - Country:US
Practice Address - Phone:210-233-7000
Practice Address - Fax:210-236-4110
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5375207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151537103Medicaid
E68564Medicare UPIN
TX151537103Medicaid