MEDICARE: DIANE A VISTA-DECK MD

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	207VG0400X	Gynecology Physician	4301070797	MI
2	207V00000X	Obstetrics & Gynecology Physician	4301070797	MI

General Provider Information

NPI Number	:	1265479703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE A VISTA-DECK MD

Provider Business Mailing Address
First Line	:	2306 MOMENTUM PLACE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60689-5323
Country	:	US
Telephone Number	:	810-720-5715
Fax Number	:	810-732-0891

Provider Business Practice Location Address
First Line	:	4727 SAINT ANTOINE ST
Second Line	:	SUITE 304
City	:	DETROIT
State	:	MI
Zip	:	48201-1461
Country	:	US
Telephone Number	:	313-745-0499
Fax Number	:	313-833-8801

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

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	02/18/2009

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Directions to “ DIANE A VISTA-DECK MD” Practice Location

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