Healthcare Provider Details

I. General information

NPI: 1023132511
Provider Name (Legal Business Name): JIMMY DIEP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4275 BURNHAM AVE STE 100
LAS VEGAS NV
89119-5400
US

IV. Provider business mailing address

700 E SILVERADO RANCH BLVD STE 170
LAS VEGAS NV
89183-7518
US

V. Phone/Fax

Practice location:
  • Phone: 702-240-6482
  • Fax: 702-240-8529
Mailing address:
  • Phone: 702-240-6482
  • Fax: 702-804-0957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number13444
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number13444
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number13444
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA111256
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: