Provider Demographics
NPI:1245405893
Name:DIAZ, MARK JEFFREY (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFREY
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 S MAIN ST
Mailing Address - Street 2:STE D
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97351-2069
Mailing Address - Country:US
Mailing Address - Phone:503-838-1951
Mailing Address - Fax:
Practice Address - Street 1:226 S MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:INDEPENDENCE
Practice Address - State:OR
Practice Address - Zip Code:97351-2070
Practice Address - Country:US
Practice Address - Phone:503-838-1951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3816111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor