Provider Demographics
NPI:1194799627
Name:FORT, DIANA KATHLEEN (MD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:KATHLEEN
Last Name:FORT
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 1:2742 MAYFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-3816
Mailing Address - Country:US
Mailing Address - Phone:818-249-9134
Mailing Address - Fax:
Practice Address - Street 1:VERDUGO HILLS MEDICAL ASSOCIATES
Practice Address - Street 2:544 NORTH GLENDALE AVE.
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206
Practice Address - Country:US
Practice Address - Phone:818-241-4331
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72238207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI46866Medicare UPIN