Provider Demographics
NPI:1275099277
Name:DIAZ, VLADIMIR
Entity Type:Individual
Prefix:
First Name:VLADIMIR
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9010 150TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-4024
Mailing Address - Country:US
Mailing Address - Phone:718-739-0520
Mailing Address - Fax:718-739-1582
Practice Address - Street 1:9010 150TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-4024
Practice Address - Country:US
Practice Address - Phone:718-739-0520
Practice Address - Fax:718-739-1582
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW217966607OtherAETNA