Provider Demographics
NPI:1538122635
Name:DIAZ, GUSTAVO A (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:A
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2300
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93902-2300
Mailing Address - Country:US
Mailing Address - Phone:831-649-1000
Mailing Address - Fax:
Practice Address - Street 1:1513 FREMONT BLVD
Practice Address - Street 2:E1
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-4319
Practice Address - Country:US
Practice Address - Phone:831-899-1910
Practice Address - Fax:831-393-9483
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA53006207P00000X
CAC54872207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000000006706OtherBMC
MA04-3329195OtherNORTH AMERICAN PREFERRED
MA04-3329195OtherGREAT-WEST
MA102531OtherCIGNA
MA2359897OtherAETNA
MA04-3329195OtherPHCS
MA04-3329195OtherUNICARE/GIC
MA04-3329195OtherNORTHEAST HEALTHCARE ALLI
MA04-3329195OtherNORTHEAST HEALTH DIRECT
MA04-3329195OtherPLAN VISTA
MA053006OtherTUFTS
MA24922OtherHEALTH NEW ENGLAND
MA3000915Medicaid
MA438822OtherHARVARD PILGRIM
MA632919OtherCONNECTICARE
MAJ08576OtherBCBS MA
MA04-3329195OtherCONSOLIDATED
MA24922OtherHEALTH NEW ENGLAND
MA3000915Medicaid