Provider Demographics
NPI:1609916790
Name:DIABLO VALLEY WOMEN OB,GYN MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:DIABLO VALLEY WOMEN OB,GYN MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLEY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:FILLMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-676-3450
Mailing Address - Street 1:2299 BACON ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-2050
Mailing Address - Country:US
Mailing Address - Phone:925-676-3450
Mailing Address - Fax:925-676-0615
Practice Address - Street 1:2299 BACON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2050
Practice Address - Country:US
Practice Address - Phone:925-676-3450
Practice Address - Fax:925-676-0615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ66213ZOtherBLUE SHIELD
CAZZZ14654ZMedicare ID - Type UnspecifiedMEDICARE