Provider Demographics
NPI:1609964717
Name:DIAZ, BRIAN DAVID (MPT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DAVID
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4221 GARRETT RD STE 2
Mailing Address - Street 2:ACTIVEDGE FITNESS & SPORTS PERFORMANCE
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-3467
Mailing Address - Country:US
Mailing Address - Phone:919-493-1204
Mailing Address - Fax:919-493-1204
Practice Address - Street 1:4221 GARRETT RD STE 2
Practice Address - Street 2:ACTIVEDGE FITNESS & SPORTS PERFORMANCE
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-3467
Practice Address - Country:US
Practice Address - Phone:919-493-1204
Practice Address - Fax:919-493-1204
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP8453225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist