Provider Demographics
NPI:1124032644
Name:DIAZ, ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:
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 1:147 REYNOIR ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39530-4109
Mailing Address - Country:US
Mailing Address - Phone:228-396-0337
Mailing Address - Fax:
Practice Address - Street 1:1720A MEDICAL PARK DR
Practice Address - Street 2:SUITE 130
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2129
Practice Address - Country:US
Practice Address - Phone:228-396-0337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07274207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00015105Medicaid
MS00015105Medicaid