Healthcare Provider Details

I. General information

NPI: 1073823332
Provider Name (Legal Business Name): DIABLO VALLEY PRIMARY CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 HIGH SCHOOL AVE SUITE 800
CONCORD CA
94520-1800
US

IV. Provider business mailing address

2415 HIGH SCHOOL AVE SUITE 800
CONCORD CA
94520-1800
US

V. Phone/Fax

Practice location:
  • Phone: 925-687-5210
  • Fax: 925-687-5091
Mailing address:
  • Phone: 925-687-5210
  • Fax: 925-687-5091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberNP14287
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG66708
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG73896
License Number StateCA

VIII. Authorized Official

Name: DR. CHINNAVUTH PITOU DE MONTEIRO
Title or Position: OWNER
Credential: M.D.
Phone: 925-687-5210