Provider Demographics
NPI:1073823332
Name:DIABLO VALLEY PRIMARY CARE, INC.
Entity Type:Organization
Organization Name:DIABLO VALLEY PRIMARY CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHINNAVUTH
Authorized Official - Middle Name:PITOU
Authorized Official - Last Name:DE MONTEIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-687-5210
Mailing Address - Street 1:2415 HIGH SCHOOL AVE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-1800
Mailing Address - Country:US
Mailing Address - Phone:925-687-5210
Mailing Address - Fax:925-687-5091
Practice Address - Street 1:2415 HIGH SCHOOL AVE
Practice Address - Street 2:SUITE 800
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1800
Practice Address - Country:US
Practice Address - Phone:925-687-5210
Practice Address - Fax:925-687-5091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66708207Q00000X
CAG73896207R00000X
CANP14287363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1558392449OtherNPI
CA1275642910OtherNPI
CA1093815540OtherNPI
CA1275642910OtherNPI
CA1558392449OtherNPI