Provider Demographics
NPI:1164523130
Name:DIAZ, GEORGE A (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
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 1:909 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1409
Mailing Address - Country:US
Mailing Address - Phone:425-317-0279
Mailing Address - Fax:425-317-0291
Practice Address - Street 1:1330 ROCKEFELLER AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1684
Practice Address - Country:US
Practice Address - Phone:425-261-4940
Practice Address - Fax:425-261-4945
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043980207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8423550Medicaid
WA8423550Medicaid
WAG8877968Medicare UPIN
WAG8853811Medicare PIN