Provider Demographics
NPI:1194734731
Name:DIABLO NEPHROLOGY MEDICAL GROUP, INC
Entity type:Organization
Organization Name:DIABLO NEPHROLOGY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:925-686-0315
Mailing Address - Street 1:2222 EAST STREET
Mailing Address - Street 2:STE 305
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-2066
Mailing Address - Country:US
Mailing Address - Phone:925-686-1230
Mailing Address - Fax:925-686-8443
Practice Address - Street 1:2222 EAST STREET
Practice Address - Street 2:STE 305
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2066
Practice Address - Country:US
Practice Address - Phone:925-686-1230
Practice Address - Fax:925-686-8443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0020610Medicaid
CAGR0020610Medicaid
CACP2044Medicare PIN