Healthcare Provider Details

I. General information

NPI: 1912002668
Provider Name (Legal Business Name): DIANE CECILE MAIWALD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

284 OAKWOOD ROAD
HUNTINGTON STATION NY
11746
US

IV. Provider business mailing address

284 OAKWOOD ROAD
HUNTINGTON STATION NY
11746
US

V. Phone/Fax

Practice location:
  • Phone: 631-423-2110
  • Fax: 631-423-8672
Mailing address:
  • Phone: 631-423-2110
  • Fax: 631-423-8672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number170366
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: