Provider Demographics
NPI:1730261132
Name:GAVIRIA, DIANA MARILYN (MD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:MARILYN
Last Name:GAVIRIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 EMMETT ROUSCH DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-6313
Mailing Address - Country:US
Mailing Address - Phone:304-263-5131
Mailing Address - Fax:304-263-1067
Practice Address - Street 1:800 EMMETT ROUSCH DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-6313
Practice Address - Country:US
Practice Address - Phone:304-263-5131
Practice Address - Fax:304-263-1067
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV175502083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0021267001Medicaid
WV0053907000Medicaid
WV0053907000Medicaid