Provider Demographics
NPI:1275127292
Name:DIAZ, BRYAN ISAI
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ISAI
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 1:81 LONGMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-1912
Mailing Address - Country:US
Mailing Address - Phone:240-678-3224
Mailing Address - Fax:
Practice Address - Street 1:18109 PRINCE PHILIP DR STE 155
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1591
Practice Address - Country:US
Practice Address - Phone:301-260-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program