Provider Demographics
NPI:1508178195
Name:SMALL, DIWARN (DPM)
Entity Type:Individual
Prefix:
First Name:DIWARN
Middle Name:
Last Name:SMALL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 DORIS ST
Mailing Address - Street 2:APT 4 F
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-4990
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1430 DORIS ST
Practice Address - Street 2:APT 4 F
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-4990
Practice Address - Country:US
Practice Address - Phone:718-825-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY65006373213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery