1386796258 NPI number — ANTONIO M. DIAZ JR MDPA INC.

Table of content: (NPI 1386796258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386796258 NPI number — ANTONIO M. DIAZ JR MDPA INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTONIO M. DIAZ JR MDPA INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1386796258
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 4119
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROWNSVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78523-4119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-541-5231
Provider Business Mailing Address Fax Number:
956-541-3230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
864 CENTRAL BLVD.
Provider Second Line Business Practice Location Address:
STE. #100
Provider Business Practice Location Address City Name:
BROWNSVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78520-7551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-541-5231
Provider Business Practice Location Address Fax Number:
956-541-3230
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PARRA
Authorized Official First Name:
ERICKA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
956-541-5231

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  E5508 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: E5508 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 116040001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1160400-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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