Provider Demographics
NPI:1275508939
Name:DIAZ, EDWIN A (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:A
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 SPRINGHILL DR
Mailing Address - Street 2:SUITE345
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117-2924
Mailing Address - Country:US
Mailing Address - Phone:501-945-2121
Mailing Address - Fax:501-537-1875
Practice Address - Street 1:3401 SPRINGHILL DR
Practice Address - Street 2:SUITE345
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2924
Practice Address - Country:US
Practice Address - Phone:501-945-2121
Practice Address - Fax:501-537-1875
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4076208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154196001Medicaid
ARP00137126OtherRAILROAD MEDICARE
5M928Medicare ID - Type Unspecified
AR154196001Medicaid