Provider Demographics
NPI:1619975091
Name:DIAZ, LUIS A (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:A
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 CASTLE HILL AVE
Mailing Address - Street 2:BRONX MEDICAL CARE ASSOC., PC
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-4804
Mailing Address - Country:US
Mailing Address - Phone:718-518-9200
Mailing Address - Fax:718-792-1029
Practice Address - Street 1:1217 CASTLE HILL AVE
Practice Address - Street 2:BRONX MEDICAL CARE ASSOC., PC
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-4804
Practice Address - Country:US
Practice Address - Phone:718-518-9200
Practice Address - Fax:718-792-1029
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
NY161575207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00957460Medicaid
NYA64393Medicare UPIN
NY81D791Medicare ID - Type Unspecified