Healthcare Provider Details

I. General information

NPI: 1144397548
Provider Name (Legal Business Name): DIANE INDYK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JACOBI MEDICAL CENTER 1400 PELHAM PARKWAY SOUTH
BRONX NY
10461
US

IV. Provider business mailing address

JACOBI MEDICAL CENTER 1400 PELHAM PARKWAY SOUTH
BRONX NY
10461
US

V. Phone/Fax

Practice location:
  • Phone: 718-918-4134
  • Fax: 718-918-4176
Mailing address:
  • Phone: 203-353-1275
  • Fax: 718-918-4176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number140247
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: