Provider Demographics
NPI:1225094253
Name:DIAZ, SUMAC (MD)
Entity Type:Individual
Prefix:
First Name:SUMAC
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7107 JAHNKE RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225
Mailing Address - Country:US
Mailing Address - Phone:804-320-4967
Mailing Address - Fax:804-320-7130
Practice Address - Street 1:7107 JAHNKE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225
Practice Address - Country:US
Practice Address - Phone:804-320-4967
Practice Address - Fax:804-320-7130
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230549174400000X, 207V00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010082595Medicaid
VAI12037Medicare UPIN
VA010082595Medicaid