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General NPI Number Information
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NPI Number | 1801097001
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Entity Type | Individual
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Provider Name | DIANA SOFIA GLACCUM-GAVAGNI M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/29/2007
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Last Update Date | 04/11/2025
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Provider Practice Location Address
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Address Line | 900 SW 196TH AVE
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City | PEMBROKE PINES
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State | FL
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Zip | 33029-1329
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Country | US
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Telephone | 954-546-2707
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Fax | 305-355-7195
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Provider Business Mailing Address
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Address Line | 20984 UPTOWN AVE APT 105
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City | BOCA RATON
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State | FL
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Zip | 33428-6579
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Country | US
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Telephone | 954-546-2707
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Fax | 954-820-5592
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | ME105239
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | ME105239
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License Number State | FL
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