Provider Demographics
NPI:1083294821
Name:DIAZ-GOMEZ, CONLEY REY (MD)
Entity Type:Individual
Prefix:
First Name:CONLEY
Middle Name:REY
Last Name:DIAZ-GOMEZ
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 1:401 MATTHEW ST
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-1699
Mailing Address - Country:US
Mailing Address - Phone:740-374-1413
Mailing Address - Fax:740-376-5078
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1699
Practice Address - Country:US
Practice Address - Phone:740-376-1939
Practice Address - Fax:740-374-1693
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program