Healthcare Provider Details

I. General information

NPI: 1740687920
Provider Name (Legal Business Name): LORAINE V. DIEGO, MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 W TEMPLE ST STE 7643
LOS ANGELES CA
90026-5421
US

IV. Provider business mailing address

PO BOX 457
SAN DIMAS CA
91773-0457
US

V. Phone/Fax

Practice location:
  • Phone: 213-388-2229
  • Fax: 213-388-1507
Mailing address:
  • Phone: 909-971-9334
  • Fax: 909-575-3573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberA67445
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA67445
License Number StateCA

VIII. Authorized Official

Name: DR. LORAINE V DIEGO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 213-388-2229