Provider Demographics
NPI:1093165540
Name:TACELOSKY, DIANA (MD, PHD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:TACELOSKY
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:FRACKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17931-1672
Mailing Address - Country:US
Mailing Address - Phone:570-874-4100
Mailing Address - Fax:570-874-4182
Practice Address - Street 1:701 W OAK ST
Practice Address - Street 2:
Practice Address - City:FRACKVILLE
Practice Address - State:PA
Practice Address - Zip Code:17931-1672
Practice Address - Country:US
Practice Address - Phone:570-874-4100
Practice Address - Fax:570-874-4182
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2024-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116029131207Q00000X
PAMD482087207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine