Provider Demographics
NPI:1912944216
Name:DIEP, JIMMY (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:
Last Name:DIEP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51238
Mailing Address - Street 2:ATTENTION: MAGGIE NOLES
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-5538
Mailing Address - Country:US
Mailing Address - Phone:562-741-4461
Mailing Address - Fax:562-741-4413
Practice Address - Street 1:4540 E 7TH ST
Practice Address - Street 2:ATTENTION: MAGGIE NOLES
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-4327
Practice Address - Country:US
Practice Address - Phone:562-344-1150
Practice Address - Fax:562-344-1155
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84643207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A846430OtherBLUE SHIELD ID #
CA00A846430Medicaid
CA00A846430OtherBLUE SHIELD ID #
CA00A846430Medicaid
CAWA84643AMedicare PIN