Healthcare Provider Details

I. General information

NPI: 1124059571
Provider Name (Legal Business Name): MARK WAYNE DIAMOND D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 INDEPENDENCE RD
CANON CITY CO
81212-9380
US

IV. Provider business mailing address

3225 INDEPENDENCE RD
CANON CITY CO
81212-9380
US

V. Phone/Fax

Practice location:
  • Phone: 719-275-2351
  • Fax: 719-269-9386
Mailing address:
  • Phone: 719-275-2351
  • Fax: 719-269-9386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number32405
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberDO126330
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: