1508803693 NPI number — MARIO HUMBERTO DIAZ MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508803693 NPI number — MARIO HUMBERTO DIAZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIAZ
Provider First Name:
MARIO
Provider Middle Name:
HUMBERTO
Provider Name Prefix Text:
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:
1508803693
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64834
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21264-4834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-481-6573
Provider Business Mailing Address Fax Number:
443-481-6515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
ACP 4TH FLOOR/SURGICAL HOSPITALIST STE.
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401-3280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-481-1372
Provider Business Practice Location Address Fax Number:
443-481-1360
Provider Enumeration Date:
05/31/2006

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: 208600000X , with the licence number:  D0022049 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4071161 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6718667 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 89468104 . This is a "CAREFIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: K585007 . This is a "CAREFIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 145726104 . This is a "FEDERAL DEPT OF LABOR (WORKMAN'S COMP)" identifier . This identifiers is of the category "OTHER".
  • Identifier: 112414 . This is a "KAISER PERMANENTE" identifier . This identifiers is of the category "OTHER".




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