1235347576 NPI number — DIANA LYNN VERDE M.D.

Table of content: DIANA LYNN VERDE M.D. (NPI 1235347576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235347576 NPI number — DIANA LYNN VERDE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VERDE
Provider First Name:
DIANA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VERDE-DAVIS
Provider Other First Name:
DIANA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1235347576
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W14302 BROOKWOOD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIPON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54971-9533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-663-0044
Provider Business Mailing Address Fax Number:
920-346-5900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
649 W OSHKOSH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIPON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54971-1040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-745-2282
Provider Business Practice Location Address Fax Number:
920-745-2280
Provider Enumeration Date:
05/18/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0015X , with the licence number:  34295-02 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: C53575 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 31956700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".