Healthcare Provider Details

I. General information

NPI: 1306973615
Provider Name (Legal Business Name): RON DIECKMANN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RONALD ALBERT DIECKMANN M.D.

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5843 BUENA VISTA AVE
OAKLAND CA
94618-2122
US

IV. Provider business mailing address

5843 BUENA VISTA AVE
OAKLAND CA
94618-2122
US

V. Phone/Fax

Practice location:
  • Phone: 510-213-1815
  • Fax: 510-213-1815
Mailing address:
  • Phone: 510-213-1815
  • Fax: 510-213-1815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG36970
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberG36970
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG36970
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: