Healthcare Provider Details

I. General information

NPI: 1184684219
Provider Name (Legal Business Name): KENNETH ROBERT DIDDIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 LA VENTA DR SUITE 211
WESTLAKE VILLAGE CA
91361-3703
US

IV. Provider business mailing address

1220 LA VENTA DR SUITE 211
WESTLAKE VILLAGE CA
91361-3703
US

V. Phone/Fax

Practice location:
  • Phone: 805-379-0200
  • Fax: 805-496-5204
Mailing address:
  • Phone: 805-379-0200
  • Fax: 805-496-5204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG033939
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: