Healthcare Provider Details

I. General information

NPI: 1710993845
Provider Name (Legal Business Name): DIANA RENEE WALLACE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 TURIN ROAD BUILDING 4, SUITE 2
ROME NY
13440-7423
US

IV. Provider business mailing address

7900 TURIN ROAD BUILDING 4, SUITE 2
ROME NY
13440-7423
US

V. Phone/Fax

Practice location:
  • Phone: 315-338-7284
  • Fax: 315-338-7286
Mailing address:
  • Phone: 315-338-7284
  • Fax: 315-338-7286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD 433457
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number255422
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD 2015-0031
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: