Healthcare Provider Details

I. General information

NPI: 1134171408
Provider Name (Legal Business Name): OCHUKO GREGSON DIAMREYAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 NORTH SIERRA WAY
SAN BERNADINO CA
92405
US

IV. Provider business mailing address

2380 NORTH SIERRA WAY
SAN BERNADINO CA
92405
US

V. Phone/Fax

Practice location:
  • Phone: 909-556-7305
  • Fax: 909-886-7305
Mailing address:
  • Phone: 909-886-7475
  • Fax: 909-886-7305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA66432
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: