Provider Demographics
NPI:1578663084
Name:FABRICIUS, DIANE LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:LOUISE
Last Name:FABRICIUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:400 LABORATORY RD STE 101
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6808
Mailing Address - Country:US
Mailing Address - Phone:865-482-1692
Mailing Address - Fax:865-482-4070
Practice Address - Street 1:400 LABORATORY RD STE 101
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6808
Practice Address - Country:US
Practice Address - Phone:865-482-1692
Practice Address - Fax:865-482-4070
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD0000030687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3836002Medicaid
TN3836002Medicaid
TNC46215Medicare UPIN