Provider Demographics
NPI:1578856159
Name:DIAZ, JONATHAN RAY (DO)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:RAY
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4613
Mailing Address - Country:US
Mailing Address - Phone:719-524-2410
Mailing Address - Fax:
Practice Address - Street 1:4110 BRIARGATE PKWY STE 405
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7838
Practice Address - Country:US
Practice Address - Phone:719-365-7300
Practice Address - Fax:719-365-7301
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS196282084N0400X
NC2016-017992084N0400X
LA3382402084N0400X
WA1014208D00000X
MO20230478562084N0400X
CODR.00625212084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice