Provider Demographics
NPI:1124082375
Name:BOURKE, DIANE A (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:A
Last Name:BOURKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:7B JOHNSON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-3003
Practice Address - Country:US
Practice Address - Phone:518-782-7733
Practice Address - Fax:518-782-0800
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1735302080P0006X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY042ZE1OtherEMPIRE BLUECROSS
NY143257OtherGHI/HMO
NY5780670OtherAETNA
NY9042526OtherMVP HELATHCARE
NY01820997Medicaid
NY091231000203OtherFIDELIS
NYPRC110027743OtherCDPHP
NY01820997Medicaid