Basic Information
| Provider Information | |||||||||
| NPI: | 1912944216 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIEP | ||||||||
| FirstName: | JIMMY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51238 | ||||||||
| Address2: | ATTENTION: MAGGIE NOLES | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900515538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5627414461 | ||||||||
| FaxNumber: | 5627414413 | ||||||||
| Practice Location | |||||||||
| Address1: | 4540 E 7TH ST | ||||||||
| Address2: | ATTENTION: MAGGIE NOLES | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908044327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5623441150 | ||||||||
| FaxNumber: | 5623441155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A84643 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A846430 | 01 | CA | BLUE SHIELD ID # | OTHER | 00A846430 | 05 | CA | MEDICAID |