Provider Demographics
NPI:1427003300
Name:DIAZ-GOMEZ, MARIO A (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:A
Last Name:DIAZ-GOMEZ
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 1:360 E 7TH ST SUITE L
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6701
Mailing Address - Country:US
Mailing Address - Phone:909-303-3047
Mailing Address - Fax:909-303-3090
Practice Address - Street 1:360 E 7TH ST
Practice Address - Street 2:SUITE L
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6701
Practice Address - Country:US
Practice Address - Phone:909-303-3047
Practice Address - Fax:909-303-3090
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56432207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG564320Medicaid
CAG564320Medicaid
CA00G564321Medicare ID - Type Unspecified