Healthcare Provider Details

I. General information

NPI: 1184155285
Provider Name (Legal Business Name): HOLLY DIEU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 01/13/2023
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 16TH ST STE 125
SANTA MONICA CA
90404-1249
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-315-8900
  • Fax: 310-315-8902
Mailing address:
  • Phone: 310-301-8707
  • Fax: 310-301-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA159955
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA159955
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: