Healthcare Provider Details

I. General information

NPI: 1285688754
Provider Name (Legal Business Name): DIANE DERMARDEROSIAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST HASBRO 122
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

26 GREENWOOD AVE
NEEDHAM MA
02492-3402
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-6484
  • Fax: 401-444-6378
Mailing address:
  • Phone: 781-710-8822
  • Fax: 781-449-2492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10774
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: