Healthcare Provider Details

I. General information

NPI: 1629259825
Provider Name (Legal Business Name): SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT OF PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL GE07
MADERA CA
93636-8761
US

IV. Provider business mailing address

9300 VALLEY CHILDRENS PL
MADERA CA
93636-8761
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-6277
  • Fax: 559-353-5424
Mailing address:
  • Phone: 559-353-6277
  • Fax: 559-353-5424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: RALPH P. DIAZ
Title or Position: PRESIDENT AND MEDICAL DIRECTOR
Credential: M.D.
Phone: 559-353-5016