Provider Demographics
NPI:1013360429
Name:DIAZ, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3900
Mailing Address - Country:US
Mailing Address - Phone:312-747-9545
Mailing Address - Fax:312-745-7603
Practice Address - Street 1:2133 W LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3707
Practice Address - Country:US
Practice Address - Phone:312-746-7824
Practice Address - Fax:312-746-6526
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001159247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001159OtherIDPHLICENSE