Provider Demographics
NPI:1962437731
Name:DECOSIMO, DIANA R (MD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:R
Last Name:DECOSIMO
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:30 BERGEN ST
Mailing Address - Street 2:ADMC 12 1205
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 BERGEN ST
Practice Address - Street 2:DOC 4400
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2425
Practice Address - Country:US
Practice Address - Phone:973-972-1880
Practice Address - Fax:973-972-1879
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2009-08-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA06131700207RC0000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6326200Medicaid
NJ545583Medicare PIN
NJ6326200Medicaid