Provider Demographics
NPI:1205190964
Name:DIAZ, VICTOR ESTEVAN (AODC #1402)
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:ESTEVAN
Last Name:DIAZ
Suffix:
Gender:M
Credentials:AODC #1402
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7545 METROPOLITAN DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4402
Mailing Address - Country:US
Mailing Address - Phone:196-718-9890
Mailing Address - Fax:619-718-9897
Practice Address - Street 1:7545 METROPOLITAN DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4402
Practice Address - Country:US
Practice Address - Phone:619-718-9890
Practice Address - Fax:619-718-9897
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 171M00000X, 172V00000X
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171M00000XMedicaid