Healthcare Provider Details

I. General information

NPI: 1265479703
Provider Name (Legal Business Name): DIANE A VISTA-DECK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4727 SAINT ANTOINE ST SUITE 304
DETROIT MI
48201-1461
US

IV. Provider business mailing address

2306 MOMENTUM PLACE
CHICAGO IL
60689-5323
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-0499
  • Fax: 313-833-8801
Mailing address:
  • Phone: 810-720-5715
  • Fax: 810-732-0891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number4301070797
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301070797
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: