=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114479961
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUNT DIABLO MEDICAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2016
-----------------------------------------------------
Last Update Date | 11/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5401 NORRIS CANYON ROAD SUITE 308
-----------------------------------------------------
City | SAN RAMON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94583-5408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-866-8822
-----------------------------------------------------
Fax | 925-866-8323
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5401 NORRIS CANYON ROAD SUITE 308
-----------------------------------------------------
City | SAN RAMON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94583-5408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-866-8822
-----------------------------------------------------
Fax | 925-866-8323
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. NARENDRA MALANI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 925-866-8822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RS0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------