Provider Demographics
NPI:1720119860
Name:DIANA, LAURA (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DIANA
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 1:65 NEILSON ST STE 101
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-2491
Mailing Address - Country:US
Mailing Address - Phone:831-786-1457
Mailing Address - Fax:831-786-1458
Practice Address - Street 1:65 NEILSON ST STE 101
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-2491
Practice Address - Country:US
Practice Address - Phone:831-786-1457
Practice Address - Fax:831-786-1458
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG075508207VC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VC0200XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G755080OtherMEDI-CAL
CAF82656Medicare UPIN