Provider Demographics
NPI:1831247998
Name:DIAMOND, MARK DOUGLAS (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DOUGLAS
Last Name:DIAMOND
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24980 TERRENO DR
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-3989
Mailing Address - Country:US
Mailing Address - Phone:951-693-2486
Mailing Address - Fax:
Practice Address - Street 1:29377 RANCHO CALIFORNIA RD
Practice Address - Street 2:SUITE 201
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5206
Practice Address - Country:US
Practice Address - Phone:951-693-2486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8771103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPJ0087710OtherMEDICAL
CA00PL87710Medicare ID - Type Unspecified