Provider Demographics
NPI:1508482027
Name:DIAZ, JUAN CARLOS (CSA)
Entity Type:Individual
Prefix:MR
First Name:JUAN CARLOS
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 W FLOURNOY ST APT 3F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3213
Mailing Address - Country:US
Mailing Address - Phone:786-658-0280
Mailing Address - Fax:
Practice Address - Street 1:1433 W FLOURNOY ST APT 3F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-3213
Practice Address - Country:US
Practice Address - Phone:786-658-0280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-20
Last Update Date:2020-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000684246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty