Basic Information
| Provider Information | |||||||||
| NPI: | 1194734731 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIABLO NEPHROLOGY MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 EAST STREET | ||||||||
| Address2: | STE 305 | ||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945202066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256861230 | ||||||||
| FaxNumber: | 9256868443 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 EAST STREET | ||||||||
| Address2: | STE 305 | ||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945202066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256861230 | ||||||||
| FaxNumber: | 9256868443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 09/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | HUTTON | ||||||||
| AuthorizedOfficialFirstName: | FAWN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9256860315 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0020610 | 05 | CA | MEDICAID |