Provider Demographics
NPI:1023312907
Name:CEFRE, DIODINIE G (PT)
Entity type:Individual
Prefix:
First Name:DIODINIE
Middle Name:G
Last Name:CEFRE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15550 ROCKFIELD BLVD
Mailing Address - Street 2:B220
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2720
Mailing Address - Country:US
Mailing Address - Phone:949-598-9999
Mailing Address - Fax:949-598-9999
Practice Address - Street 1:309 S ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3602
Practice Address - Country:US
Practice Address - Phone:310-652-8404
Practice Address - Fax:310-652-7470
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29490174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT29490OtherPT LICENSE