Healthcare Provider Details

I. General information

NPI: 1740353614
Provider Name (Legal Business Name): CAROLE GAIL KOHEN-DINIAK D O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1801
US

IV. Provider business mailing address

ARROWHEAD PEDIATRICS MEDICAL GROUP 400 NORTH PEPPER AVENUE, 2 MOB 203
COLTON CA
92324
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-3380
  • Fax: 909-580-6361
Mailing address:
  • Phone: 909-580-3380
  • Fax: 909-580-6361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A15780
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: