Provider Demographics
NPI:1306973615
Name:DIECKMANN, RON (MD)
Entity type:Individual
Prefix:
First Name:RON
Middle Name:
Last Name:DIECKMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RONALD
Other - Middle Name:ALBERT
Other - Last Name:DIECKMANN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5843 BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-2122
Mailing Address - Country:US
Mailing Address - Phone:510-213-1815
Mailing Address - Fax:510-213-1815
Practice Address - Street 1:5843 BUENA VISTA AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-2122
Practice Address - Country:US
Practice Address - Phone:510-213-1815
Practice Address - Fax:510-213-1815
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36970207P00000X, 207PP0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G369700Medicaid
CA00G369700Medicare ID - Type Unspecified
A46889Medicare UPIN