Healthcare Provider Details

I. General information

NPI: 1477793750
Provider Name (Legal Business Name): DIANA DAWN DUTRA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2009
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MEDICAL CENTER DR
PHILIPSBURG PA
16866-5500
US

IV. Provider business mailing address

100 NORTH ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 814-342-5402
  • Fax: 814-342-0598
Mailing address:
  • Phone: 570-214-5681
  • Fax: 570-271-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS016007
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: