Provider Demographics
NPI:1962409409
Name:TENENBAUM, DIANE CANTOR (MD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:CANTOR
Last Name:TENENBAUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:ROCHELLE
Other - Last Name:CANTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1092 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-2248
Mailing Address - Country:US
Mailing Address - Phone:518-525-2445
Mailing Address - Fax:518-475-7069
Practice Address - Street 1:1092 MADISON AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-2248
Practice Address - Country:US
Practice Address - Phone:518-525-2445
Practice Address - Fax:518-475-7069
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228318208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02492322Medicaid
NY02492322Medicaid