MEDICARE: MRS. DIANE WALLACE KECSKES M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	G74951	CA
2	2084P0005X	Neurodevelopmental Disabilities Physician	G074951	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649208638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIANE WALLACE KECSKES M.D

Provider Business Mailing Address
First Line	:	732 N RUSSELL AVE
Second Line	:
City	:	CLOVIS
State	:	CA
Zip	:	93611-0329
Country	:	US
Telephone Number	:	559-289-6853
Fax Number	:	559-299-2587

Provider Business Practice Location Address
First Line	:	2550 W CLINTON AVE BLDG A
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93705-4206
Country	:	US
Telephone Number	:	559-264-7521
Fax Number	:	559-233-0016

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	03/13/2025

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