Provider Demographics
NPI:1154321123
Name:JERNG, DIANE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JERNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1188 N EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1900
Mailing Address - Country:US
Mailing Address - Phone:888-988-2800
Mailing Address - Fax:714-254-2871
Practice Address - Street 1:1188 N EUCLID ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1900
Practice Address - Country:US
Practice Address - Phone:888-988-2800
Practice Address - Fax:714-254-2871
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63585207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BJ5686704OtherDEA
CA00A635850Medicare ID - Type UnspecifiedMEDI-CAL
BJ5686704OtherDEA
WA63585AMedicare ID - Type Unspecified