Provider Demographics
NPI:1861514465
Name:DIABLO MUIR PODIATRY GROUP
Entity type:Organization
Organization Name:DIABLO MUIR PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:EBISUI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:925-634-9704
Mailing Address - Street 1:9030 BRENTWOOD BLVD
Mailing Address - Street 2:C
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-4095
Mailing Address - Country:US
Mailing Address - Phone:925-634-9704
Mailing Address - Fax:925-634-5757
Practice Address - Street 1:81 BOLLA AVE
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:CA
Practice Address - Zip Code:94507-1342
Practice Address - Country:US
Practice Address - Phone:925-634-9704
Practice Address - Fax:925-634-5757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE12380213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10849Medicare UPIN
CA000E12380Medicare ID - Type Unspecified