Healthcare Provider Details

I. General information

NPI: 1578917936
Provider Name (Legal Business Name): JOSE LUIS DIEGO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 OAKDALE RD STE 420
MODESTO CA
95355-3364
US

IV. Provider business mailing address

1516 TRAILS WAY
MODESTO CA
95357-0622
US

V. Phone/Fax

Practice location:
  • Phone: 209-522-3362
  • Fax:
Mailing address:
  • Phone: 209-581-3052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036161333
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA185841
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: