Provider Demographics
NPI:1447454061
Name:DIVERSIFY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:DIVERSIFY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MING-CHANG
Authorized Official - Middle Name:
Authorized Official - Last Name:HSU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-571-5577
Mailing Address - Street 1:3318 DEL MAR AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-2373
Mailing Address - Country:US
Mailing Address - Phone:626-571-5577
Mailing Address - Fax:626-571-7405
Practice Address - Street 1:3318 DEL MAR AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-2373
Practice Address - Country:US
Practice Address - Phone:626-571-5577
Practice Address - Fax:626-571-7405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34714261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center