Provider Demographics
NPI:1447323951
Name:BEDROSIAN, DIANE H (MD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:H
Last Name:BEDROSIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 THUNDER DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6010
Mailing Address - Country:US
Mailing Address - Phone:760-941-3630
Mailing Address - Fax:760-941-1214
Practice Address - Street 1:2067 W VISTA WAY STE 280
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6034
Practice Address - Country:US
Practice Address - Phone:760-941-3630
Practice Address - Fax:760-941-3879
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70705208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G707050Medicaid
CA5346695OtherAETNA
CA00G707050Medicaid
CA00G707050OtherBLUE CROSS BLUE SHIELD
CAWG70705CMedicare PIN