Provider Demographics
NPI:1063675650
Name:DIAZ, KYLE I (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:I
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-5207
Mailing Address - Country:US
Mailing Address - Phone:870-779-6000
Mailing Address - Fax:870-779-6093
Practice Address - Street 1:300 E 6TH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-5207
Practice Address - Country:US
Practice Address - Phone:870-779-6000
Practice Address - Fax:870-779-6093
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE6586207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine