Healthcare Provider Details

I. General information

NPI: 1649208638
Provider Name (Legal Business Name): DIANE WALLACE KECSKES M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 W CLINTON AVE BLDG A
FRESNO CA
93705-4206
US

IV. Provider business mailing address

732 N RUSSELL AVE
CLOVIS CA
93611-0329
US

V. Phone/Fax

Practice location:
  • Phone: 559-264-7521
  • Fax: 559-233-0016
Mailing address:
  • Phone: 559-289-6853
  • Fax: 559-299-2587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License NumberG074951
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG74951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: