Provider Demographics
NPI:1598367674
Name:DIAZ-VAZQUEZ, DOMINGO
Entity Type:Individual
Prefix:
First Name:DOMINGO
Middle Name:
Last Name:DIAZ-VAZQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 E STROOP RD UNIT 292633
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-7537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6728 RAVEN CRST
Practice Address - Street 2:
Practice Address - City:LIBERTY TWP
Practice Address - State:OH
Practice Address - Zip Code:45011-9235
Practice Address - Country:US
Practice Address - Phone:937-270-7163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker