Provider Demographics
NPI:1508803693
Name:DIAZ, MARIO HUMBERTO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:HUMBERTO
Last Name:DIAZ
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:PO BOX 64834
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4834
Mailing Address - Country:US
Mailing Address - Phone:443-481-6573
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2001 MEDICAL PKWY
Practice Address - Street 2:ACP 4TH FLOOR/SURGICAL HOSPITALIST STE.
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3280
Practice Address - Country:US
Practice Address - Phone:443-481-1372
Practice Address - Fax:443-481-1360
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0022049208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
4071161OtherAETNA PPO
6718667OtherAETNA HMO
89468104OtherCAREFIRST
K585007OtherCAREFIRST
145726104OtherFEDERAL DEPT OF LABOR (WORKMAN'S COMP)
112414OtherKAISER PERMANENTE
112414OtherKAISER PERMANENTE
4071161OtherAETNA PPO
K585007OtherCAREFIRST
689L140565ZADNMedicare PIN