Provider Demographics
NPI:1508802240
Name:DIAZ, ANTHONY JAMES (DPT)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:JAMES
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:NY
Mailing Address - Zip Code:14103
Mailing Address - Country:US
Mailing Address - Phone:585-798-4344
Mailing Address - Fax:585-798-0439
Practice Address - Street 1:711 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103
Practice Address - Country:US
Practice Address - Phone:585-798-4344
Practice Address - Fax:585-798-0439
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020582225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000625923004OtherCOMMUNITY BLUE
205707500OtherACS DOL
00021030201OtherUNIVERA
0205821OtherLICENSE
040511000802OtherFIDELIS
7362441OtherAETNA
00210030201OtherUNIVERA
NY02243158Medicaid
9310818OtherINDEPENDENT HEALTH
P010020582OtherRIPA
000625923003OtherCOMMUNITY BLUE
000625923003OtherCOMMUNITY BLUE
7362441OtherAETNA