MEDICARE: DAWN GARDINER-DIAZ

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	174400000X	Specialist	NY
3	174400000X	Specialist

General Provider Information

NPI Number	:	1558756163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAWN GARDINER-DIAZ

Provider Business Mailing Address
First Line	:	5 COONLEY CT
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10303-2216
Country	:	US
Telephone Number	:	718-552-6857
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 CONEY ISLAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-5808
Country	:	US
Telephone Number	:	718-998-1416
Fax Number	:

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

Provider Enumeration Date	:	03/31/2015
Last Update Date	:	07/22/2019

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