Healthcare Provider Details

I. General information

NPI: 1235372376
Provider Name (Legal Business Name): DIYA H TANTAWI MD, FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2009
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74000 CNTY CLUB DR STE A2
PALM DESERT CA
92260-1677
US

IV. Provider business mailing address

74000 CNTY CLUB DR STE A2
PALM DESERT CA
92260-1677
US

V. Phone/Fax

Practice location:
  • Phone: 760-666-6121
  • Fax:
Mailing address:
  • Phone: 760-666-6121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License NumberA126218
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberA126218
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA126218
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: