Provider Demographics
NPI:1417138439
Name:DIAZ, SERGIO A (MD)
Entity Type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:A
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SERGIO
Other - Middle Name:A
Other - Last Name:DIAZ VALDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3889
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3889
Mailing Address - Country:US
Mailing Address - Phone:423-794-5520
Mailing Address - Fax:423-282-6940
Practice Address - Street 1:301 MED TECH PKWY STE 240
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2641
Practice Address - Country:US
Practice Address - Phone:423-794-5520
Practice Address - Fax:423-282-6940
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43908207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508669Medicaid
TN1508669Medicaid