Healthcare Provider Details

I. General information

NPI: 1720087224
Provider Name (Legal Business Name): DIANE PINCUS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 W MOUNTAIN VIEW AVE
LONGMONT CO
80501-3128
US

IV. Provider business mailing address

1925 W MOUNTAIN VIEW AVE
LONGMONT CO
80501-3128
US

V. Phone/Fax

Practice location:
  • Phone: 303-776-1234
  • Fax: 720-494-3107
Mailing address:
  • Phone: 303-776-1234
  • Fax: 720-494-3107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number31960
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: