Provider Demographics
NPI:1326381625
Name:CORNAVACA DIAZ, CALIXTO JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:CALIXTO
Middle Name:JOSE
Last Name:CORNAVACA DIAZ
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:578 S ENOTA DR NE STE C
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-8947
Mailing Address - Country:US
Mailing Address - Phone:470-892-6607
Mailing Address - Fax:470-290-8474
Practice Address - Street 1:578 S ENOTA DR NE
Practice Address - Street 2:STE C
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4392
Practice Address - Country:US
Practice Address - Phone:423-619-8381
Practice Address - Fax:470-290-8474
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA74951208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice