1235875105 NPI number — MANUEL ANTONIO DIAZ ROSADO

Table of content: MANUEL ANTONIO DIAZ ROSADO (NPI 1235875105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235875105 NPI number — MANUEL ANTONIO DIAZ ROSADO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIAZ ROSADO
Provider First Name:
MANUEL
Provider Middle Name:
ANTONIO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1235875105
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
590 MEDICAL CENTER ROAD, DARNALL ARMY MEDICAL CENTER
Provider Second Line Business Mailing Address:
EMERGENCY MEDICINE, RESIDENCY CENTER
Provider Business Mailing Address City Name:
FORT CAVAZOS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-553-9089
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
590 MEDICAL CENTER ROAD, DARNALL ARMY MEDICAL CENTER
Provider Second Line Business Practice Location Address:
EMERGENCY MEDICINE, RESIDENCY CENTER
Provider Business Practice Location Address City Name:
FORT CAVAZOS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76544-5060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-553-9089
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/12/2022

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: 390200000X , with the licence number:  BP10086842 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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