Healthcare Provider Details

I. General information

NPI: 1558117564
Provider Name (Legal Business Name): DIEGO TIMOTEO PEDRAZA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BERCUT DR
SACRAMENTO CA
95811-0131
US

IV. Provider business mailing address

3780 ROSIN CT STE 110
SACRAMENTO CA
95834-1698
US

V. Phone/Fax

Practice location:
  • Phone: 916-440-1500
  • Fax: 916-440-1514
Mailing address:
  • Phone: 916-441-0226
  • Fax: 916-441-0286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-VCJLOZ
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: