1407019532 NPI number — DR. DIEGO F DIAZ MD

Table of content: DR. DIEGO F DIAZ MD (NPI 1407019532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407019532 NPI number — DR. DIEGO F DIAZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIAZ
Provider First Name:
DIEGO
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407019532
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3158
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-3158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-215-6494
Provider Business Mailing Address Fax Number:
503-215-6644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4920 N INTERSTATE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97217-3653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-215-3300
Provider Business Practice Location Address Fax Number:
503-215-3350
Provider Enumeration Date:
07/09/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  11014152A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QS0010X , with the licence number: MD159017 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD159017 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500649902 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".