Healthcare Provider Details

I. General information

NPI: 1306029285
Provider Name (Legal Business Name): SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT OF UROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL MB16
MADERA CA
93636-8761
US

IV. Provider business mailing address

9300 VALLEY CHILDRENS PL MB16
MADERA CA
93636-8761
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-6195
  • Fax: 559-353-6196
Mailing address:
  • Phone: 559-353-6195
  • Fax: 559-353-6196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: RALPH DIAZ
Title or Position: PRESIDENT AND MEDICAL DIRECTOR
Credential: M.D.
Phone: 559-353-5700