Provider Demographics
NPI:1063830966
Name:GONGORA, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:GONGORA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 MALCOLM X BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-1802
Mailing Address - Country:US
Mailing Address - Phone:212-939-1000
Mailing Address - Fax:
Practice Address - Street 1:305 LENOX AVE
Practice Address - Street 2:HARLEM HOSP.
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037
Practice Address - Country:US
Practice Address - Phone:212-939-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-29
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001279221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001279Medicaid