Provider Demographics
NPI:1295878247
Name:DIAMOND, IRA A (DPM)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:A
Last Name:DIAMOND
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W BONITA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2543
Mailing Address - Country:US
Mailing Address - Phone:909-599-0981
Mailing Address - Fax:909-592-0738
Practice Address - Street 1:425 W BONITA AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2543
Practice Address - Country:US
Practice Address - Phone:909-599-0981
Practice Address - Fax:909-592-0738
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2340213EP0504X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E23400Medicaid
CAT11295Medicare UPIN
CA000E23400Medicaid