Provider Demographics
NPI:1962437269
Name:DIRAIMONDO, CHARLES V (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:V
Last Name:DIRAIMONDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 HIGH SCHOOL AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-1819
Mailing Address - Country:US
Mailing Address - Phone:925-798-2650
Mailing Address - Fax:925-671-9173
Practice Address - Street 1:2485 HIGH SCHOOL AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1819
Practice Address - Country:US
Practice Address - Phone:925-798-2650
Practice Address - Fax:925-671-9173
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60786174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G607862OtherMEDICARE PTAN
00G607862OtherMEDICARE PTAN
CAA53612Medicare UPIN
CA0421100001Medicare NSC