Provider Demographics
NPI:1467147850
Name:DIAZ GOMEZ, OLIVER (MD)
Entity Type:Individual
Prefix:
First Name:OLIVER
Middle Name:
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 1:1204 GREYMONT AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2155
Mailing Address - Country:US
Mailing Address - Phone:407-968-1080
Mailing Address - Fax:
Practice Address - Street 1:764 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4651
Practice Address - Country:US
Practice Address - Phone:601-984-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-5115207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine