Provider Demographics
NPI:1194781468
Name:MAIA, DIANE (MD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MAIA
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:PO BOX 758994
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-6412
Mailing Address - Country:US
Mailing Address - Phone:757-889-5069
Mailing Address - Fax:757-889-5948
Practice Address - Street 1:150 KINGSLEY LANE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505
Practice Address - Country:US
Practice Address - Phone:757-889-5146
Practice Address - Fax:757-889-5948
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101226182207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6607195Medicaid
VA6607195Medicaid
VA220000745Medicare ID - Type Unspecified
830008362Medicare PIN