Provider Demographics
NPI:1164599825
Name:DIAZ, GUSTAVO ADOLFO (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ADOLFO
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 1:17026 CARLTON WAY RD
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078
Mailing Address - Country:US
Mailing Address - Phone:251-753-2209
Mailing Address - Fax:
Practice Address - Street 1:411 N SECTION ST STE 5
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-2650
Practice Address - Country:US
Practice Address - Phone:251-517-5050
Practice Address - Fax:251-517-5049
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL25353207YS0123X
FLME103280207YS0123X
NC02055207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH77220Medicare UPIN