Provider Demographics
NPI:1598128217
Name:DIAZ, OLGA YASHIRA
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:YASHIRA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 BURROUGHS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-6619
Mailing Address - Country:US
Mailing Address - Phone:619-787-2699
Mailing Address - Fax:
Practice Address - Street 1:2004 BURROUGHS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-6619
Practice Address - Country:US
Practice Address - Phone:619-787-2699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA156210207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program