Provider Demographics
NPI:1114009693
Name:DIAZ, DAVID G (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
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 1:9 GREENBIER LN
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:714-513-1399
Mailing Address - Fax:714-513-1393
Practice Address - Street 1:11160 WARNER AVE
Practice Address - Street 2:SUITE # 411
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4008
Practice Address - Country:US
Practice Address - Phone:714-513-1399
Practice Address - Fax:714-513-1393
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35698174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist