Provider Demographics
NPI:1194812164
Name:WAGNER, DIANE (MD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:WAGNER
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 1:43 SHEBAR DR
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-4409
Mailing Address - Country:US
Mailing Address - Phone:631-581-1119
Mailing Address - Fax:
Practice Address - Street 1:43 SHEBAR DR
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-4409
Practice Address - Country:US
Practice Address - Phone:631-581-1119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182713207ZB0001X, 207ZM0300X, 207ZP0102X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Not Answered207ZM0300XAllopathic & Osteopathic PhysiciansPathologyMedical Microbiology
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY375BQ1Medicare ID - Type Unspecified