Provider Demographics
NPI:1437190113
Name:DIAZ, TEODORO G III (DO)
Entity Type:Individual
Prefix:DR
First Name:TEODORO
Middle Name:G
Last Name:DIAZ
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:TEODORO
Other - Middle Name:G
Other - Last Name:DIAZ
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:3550 E PHILADELPHIA ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-2962
Mailing Address - Country:US
Mailing Address - Phone:909-773-0022
Mailing Address - Fax:909-781-6013
Practice Address - Street 1:3550 E PHILADELPHIA ST
Practice Address - Street 2:SUITE 150
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-2962
Practice Address - Country:US
Practice Address - Phone:909-773-0022
Practice Address - Fax:909-781-6013
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine