Provider Demographics
NPI:1154999878
Name:GUILLAUME, DIANA (MD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:GUILLAUME
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 1:3500 N BROAD ST RM 1A
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-4106
Mailing Address - Country:US
Mailing Address - Phone:215-926-9019
Mailing Address - Fax:217-872-0849
Practice Address - Street 1:7602 CENTRAL AVE STE 101
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2443
Practice Address - Country:US
Practice Address - Phone:215-969-2900
Practice Address - Fax:215-969-1856
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125078974207Q00000X
PAMD485943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine