Healthcare Provider Details

I. General information

NPI: 1003897398
Provider Name (Legal Business Name): DIANE MARIE MACDONNELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 GLEN ST
GLENS FALLS NY
12801-2906
US

IV. Provider business mailing address

461 GLEN ST
GLENS FALLS NY
12801-2906
US

V. Phone/Fax

Practice location:
  • Phone: 518-745-5889
  • Fax: 518-745-0010
Mailing address:
  • Phone: 518-745-5889
  • Fax: 518-745-0010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number172673-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: