Provider Demographics
NPI:1316321508
Name:VACA, DIANA P (MD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:P
Last Name:VACA
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 1:3032 CORLEAR AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-5141
Mailing Address - Country:US
Mailing Address - Phone:718-548-4040
Mailing Address - Fax:718-548-3939
Practice Address - Street 1:3032 CORLEAR AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5141
Practice Address - Country:US
Practice Address - Phone:718-548-4040
Practice Address - Fax:718-548-3939
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY295001208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYFB9781611OtherDEA