1801941281 NPI number — DR. RUTH BAUTISTA DIAZ M.D.

Table of content: DR. RUTH BAUTISTA DIAZ M.D. (NPI 1801941281)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801941281 NPI number — DR. RUTH BAUTISTA DIAZ M.D.

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DIAZ
Provider Other First Name:
RUTH
Provider Other Middle Name:
B.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1801941281
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
08/19/2021
NPI Reactivation Date:
09/01/2021

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45 E LEWIS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48160-1119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-439-2303
Provider Business Mailing Address Fax Number:
734-439-0016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4870 W CLARK RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
YPSILANTI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48197-1104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-434-7260
Provider Business Practice Location Address Fax Number:
734-434-7607
Provider Enumeration Date:
01/24/2007

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: 2084P0800X , with the licence number:  4301035476 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 260817222 . This is a "BCBSM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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