Provider Demographics
NPI:1114946415
Name:DIAZ, ANGEL A (MD)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:A
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 1:821 PRE EMPTION RD STE 300
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-2061
Mailing Address - Country:US
Mailing Address - Phone:315-787-5310
Mailing Address - Fax:315-787-5314
Practice Address - Street 1:821 PRE EMPTION RD STE 300
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-2061
Practice Address - Country:US
Practice Address - Phone:315-787-5310
Practice Address - Fax:315-787-5314
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205857207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02146298Medicaid
NYDD6103Medicare ID - Type Unspecified
NY02146298Medicaid