Provider Demographics
NPI:1316013931
Name:DIAMOND BAR EAR NOSE & THROAT SPECIALTY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:DIAMOND BAR EAR NOSE & THROAT SPECIALTY MEDICAL GROUP, INC.
Other - Org Name:SCOTT ENT SPECIALTY GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:909-860-7712
Mailing Address - Street 1:1111 GRAND AVE., SUITE E
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2227
Mailing Address - Country:US
Mailing Address - Phone:909-860-7712
Mailing Address - Fax:909-861-1311
Practice Address - Street 1:1111 GRAND AVE., SUITE E
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-2227
Practice Address - Country:US
Practice Address - Phone:909-860-7712
Practice Address - Fax:909-861-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54536207Y00000X
207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13677Medicare ID - Type Unspecified