Provider Demographics
NPI:1659342012
Name:RUIZ DIAZ, MIGUEL A (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
Last Name:RUIZ 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 1:8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-6805
Mailing Address - Fax:952-853-8864
Practice Address - Street 1:4730 CHICAGO AVE # MS 26602G
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3570
Practice Address - Country:US
Practice Address - Phone:952-883-6805
Practice Address - Fax:952-853-8864
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38315207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN517014100Medicaid
G17836Medicare UPIN
110004959Medicare ID - Type Unspecified