Provider Demographics
NPI:1801097001
Name:GLACCUM-GAVAGNI, DIANA SOFIA (MD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:SOFIA
Last Name:GLACCUM-GAVAGNI
Suffix:
Gender:
Credentials:MD
Other - Prefix:DR
Other - First Name:DIANA
Other - Middle Name:SOFIA
Other - Last Name:GLACCUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:20984 UPTOWN AVE APT 105
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-6579
Mailing Address - Country:US
Mailing Address - Phone:954-546-2707
Mailing Address - Fax:954-820-5592
Practice Address - Street 1:900 SW 196TH AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-1329
Practice Address - Country:US
Practice Address - Phone:954-546-2707
Practice Address - Fax:305-355-7195
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1052392084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001754800Medicaid