Basic Information
| Provider Information | |||||||||
| NPI: | 1073823332 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIABLO VALLEY PRIMARY CARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2415 HIGH SCHOOL AVE | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945201800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256875210 | ||||||||
| FaxNumber: | 9256875091 | ||||||||
| Practice Location | |||||||||
| Address1: | 2415 HIGH SCHOOL AVE | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945201800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256875210 | ||||||||
| FaxNumber: | 9256875091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2010 | ||||||||
| LastUpdateDate: | 10/20/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DE MONTEIRO | ||||||||
| AuthorizedOfficialFirstName: | CHINNAVUTH | ||||||||
| AuthorizedOfficialMiddleName: | PITOU | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9256875210 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G66708 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LP2300X | NP14287 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 207R00000X | G73896 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1558392449 | 01 | CA | NPI | OTHER | 1275642910 | 01 | CA | NPI | OTHER | 1093815540 | 01 | CA | NPI | OTHER |