Provider Demographics
NPI:1730241241
Name:SANSONETTI, DIANE (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:SANSONETTI
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 1:38 CEDAR HILL PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-1907
Mailing Address - Country:US
Mailing Address - Phone:505-821-1636
Mailing Address - Fax:
Practice Address - Street 1:5600 WYOMING BLVD NE STE 10
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-821-5404
Practice Address - Fax:505-821-3148
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM87-284208G00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMC98082Medicare UPIN