Healthcare Provider Details

I. General information

NPI: 1962409409
Provider Name (Legal Business Name): DIANE CANTOR TENENBAUM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANE ROCHELLE CANTOR M.D.

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 08/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1092 MADISON AVE
ALBANY NY
12208-2248
US

IV. Provider business mailing address

1092 MADISON AVE
ALBANY NY
12208-2248
US

V. Phone/Fax

Practice location:
  • Phone: 518-525-2445
  • Fax: 518-475-7069
Mailing address:
  • Phone: 518-525-2445
  • Fax: 518-475-7069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number228318
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: