Provider Demographics
NPI:1376578500
Name:DIAZ, FREDIE C (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDIE
Middle Name:C
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 1:3900 LAS ESTANCIAS CT SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121
Mailing Address - Country:US
Mailing Address - Phone:505-727-4200
Mailing Address - Fax:505-727-4949
Practice Address - Street 1:3900 LAS ESTANCIAS CT SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121
Practice Address - Country:US
Practice Address - Phone:505-727-4200
Practice Address - Fax:505-727-4949
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199224207R00000X
NMMD2016-0863207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01752607Medicaid
NY7855020OtherAETNA
NYOX7112OtherEMPIRE BC.BS
NY01752607Medicaid
NYOX7111Medicare PIN
NYG61061Medicare UPIN