MEDICARE: DIABLO INFECTIOUS DISEASE CONSULTATIVE SERVICE MED GRP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0200X	Infectious Disease Physician

General Provider Information

NPI Number	:	1952376535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIABLO INFECTIOUS DISEASE CONSULTATIVE SERVICE MED GRP INC

Provider Business Mailing Address
First Line	:	PO BOX 20309
Second Line	:
City	:	CASTRO VALLEY
State	:	CA
Zip	:	94546-8309
Country	:	US
Telephone Number	:	925-463-1318
Fax Number	:

Provider Business Practice Location Address
First Line	:	13851 E 14TH ST STE 308
Second Line	:
City	:	SAN LEANDRO
State	:	CA
Zip	:	94578-2630
Country	:	US
Telephone Number	:	925-463-1318
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LI KUO KONG
Credential	:	MD
Telephone Number	:	925-463-1318

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	07/24/2023

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