MEDICARE: DR. MARK WAYNE DIAMOND D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	32405	CO
2	2084F0202X	Forensic Psychiatry Physician	DO126330	OR

General Provider Information

NPI Number	:	1124059571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK WAYNE DIAMOND D.O.

Provider Business Mailing Address
First Line	:	3225 INDEPENDENCE RD
Second Line	:
City	:	CANON CITY
State	:	CO
Zip	:	81212-9380
Country	:	US
Telephone Number	:	719-275-2351
Fax Number	:	719-269-9386

Provider Business Practice Location Address
First Line	:	3225 INDEPENDENCE RD
Second Line	:
City	:	CANON CITY
State	:	CO
Zip	:	81212-9380
Country	:	US
Telephone Number	:	719-275-2351
Fax Number	:	719-269-9386

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	08/27/2013

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