Provider Demographics
NPI:1437811692
Name:DIAZ, JUSTIN (PT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-1420 KULEWA LOOP APT E
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-4618
Mailing Address - Country:US
Mailing Address - Phone:808-796-7968
Mailing Address - Fax:
Practice Address - Street 1:94-1420 KULEWA LOOP APT E
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-4618
Practice Address - Country:US
Practice Address - Phone:808-796-7968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-4670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist