Provider Demographics
NPI:1417953878
Name:DIABLO VALLEY ONCOLOGY AND HEMATOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:DIABLO VALLEY ONCOLOGY AND HEMATOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:SIROTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-677-5041
Mailing Address - Street 1:400 TAYLOR BLVD
Mailing Address - Street 2:STE 202
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-2147
Mailing Address - Country:US
Mailing Address - Phone:925-677-5041
Mailing Address - Fax:925-677-5025
Practice Address - Street 1:400 TAYLOR BLVD
Practice Address - Street 2:STE 202
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-2147
Practice Address - Country:US
Practice Address - Phone:925-677-5041
Practice Address - Fax:925-677-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73460207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6190930001Medicare NSC
CAZZZ19745ZMedicare ID - Type UnspecifiedMEDICARE