Healthcare Provider Details

I. General information

NPI: 1225060643
Provider Name (Legal Business Name): DIEGO MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MUSTANG RD
RANCHO PALOS VERDES CA
90275-5250
US

IV. Provider business mailing address

23517 MAIN ST STE 101
CARSON CA
90745-5227
US

V. Phone/Fax

Practice location:
  • Phone: 310-549-2840
  • Fax: 310-549-3115
Mailing address:
  • Phone: 310-549-2840
  • Fax: 310-549-3115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA60216
License Number StateCA

VIII. Authorized Official

Name: DR. ALICE DIEGO-MALIT
Title or Position: PHYSICIAN
Credential: MD
Phone: 310-549-2840