Provider Demographics
NPI:1215038138
Name:SIMEONE, DIANE MARIE (MD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:SIMEONE
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:FILE 57326
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-7326
Mailing Address - Country:US
Mailing Address - Phone:800-926-8273
Mailing Address - Fax:
Practice Address - Street 1:3855 HEALTH SCIENCES DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-4744
Practice Address - Country:US
Practice Address - Phone:800-926-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG195633208600000X
MI4301053273208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3169854Medicaid
MIG12608Medicare UPIN
MI0H16112064Medicare ID - Type Unspecified