Basic Information
| Provider Information | |||||||||
| NPI: | 1265445993 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIABLO NEUROSURGICAL MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 SE STONE MILL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986843544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605149040 | ||||||||
| FaxNumber: | 3605149041 | ||||||||
| Practice Location | |||||||||
| Address1: | 1455 MONTEGO ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259370404 | ||||||||
| FaxNumber: | 9259371340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 04/07/2009 | ||||||||
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| AuthorizedOfficialLastName: | CHEN | ||||||||
| AuthorizedOfficialFirstName: | TERENCE | ||||||||
| AuthorizedOfficialMiddleName: | LING | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9259370404 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | ZZZ72795Z | 01 | BLUE SHIELD OF CA | OTHER | C41006 | 01 | RAILROAD MEDICARE | OTHER |