Provider Demographics
NPI:1639168222
Name:DIAZ, GLORIA ISABEL (MD)
Entity Type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:ISABEL
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-2869
Mailing Address - Country:US
Mailing Address - Phone:309-624-9400
Mailing Address - Fax:309-624-2280
Practice Address - Street 1:2805 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-2869
Practice Address - Country:US
Practice Address - Phone:309-624-9400
Practice Address - Fax:309-624-2280
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840Medicare ID - Type UnspecifiedGROUP
ILK34313Medicare ID - Type UnspecifiedINDIVIDUAL #
ILI45417Medicare UPIN