Provider Demographics
NPI:1225029762
Name:PERRY, DIANA VANESSA (MD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:VANESSA
Last Name:PERRY
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 1:9 CORTLAND DR
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-3311
Mailing Address - Country:US
Mailing Address - Phone:781-718-4934
Mailing Address - Fax:
Practice Address - Street 1:55 FOGG ROAD
Practice Address - Street 2:SOUTH SHORE MEDICAL CENTER
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190
Practice Address - Country:US
Practice Address - Phone:781-340-8373
Practice Address - Fax:781-340-3699
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA155376208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0102440Medicaid
MA155376OtherTUFTS HEALTH PLAN
H32186Medicare UPIN
MA0102440Medicaid