Provider Demographics
NPI:1811130123
Name:GEORGE, DIANE TERESA (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:TERESA
Last Name:GEORGE
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 1:5960 FAIRVIEW RD STE 500
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3113
Mailing Address - Country:US
Mailing Address - Phone:803-913-4500
Mailing Address - Fax:
Practice Address - Street 1:16817 MARVIN RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2196
Practice Address - Country:US
Practice Address - Phone:803-913-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-00850207R00000X, 207RR0500X
SC91931207RR0500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1591Medicaid
NC1811130123Medicaid
NC5920351Medicaid
NCNC7765AMedicare PIN