Healthcare Provider Details

I. General information

NPI: 1124054689
Provider Name (Legal Business Name): DIEGO MECHOSO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 01/05/2024
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15107 VANOWEN ST
VAN NUYS CA
91405-4542
US

IV. Provider business mailing address

PO BOX 60400
PASADENA CA
91116-6400
US

V. Phone/Fax

Practice location:
  • Phone: 818-902-5771
  • Fax:
Mailing address:
  • Phone: 310-462-6215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA84467
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberA84467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: