Provider Demographics
NPI:1902097389
Name:DIANE K. DWORKIN DPM LLC
Entity Type:Organization
Organization Name:DIANE K. DWORKIN DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DWORKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-243-0700
Mailing Address - Street 1:631 BROADWAY
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:631 BROADWAY
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3846
Practice Address - Country:US
Practice Address - Phone:201-243-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00212600213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty