Provider Demographics
NPI:1669453775
Name:DIAZ, ROBERTO (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
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 1:1828 EL CAMINO REAL
Mailing Address - Street 2:SUITE 601
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3103
Mailing Address - Country:US
Mailing Address - Phone:650-692-9111
Mailing Address - Fax:650-692-9114
Practice Address - Street 1:1828 EL CAMINO REAL
Practice Address - Street 2:SUITE 601
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3103
Practice Address - Country:US
Practice Address - Phone:650-692-9111
Practice Address - Fax:650-692-9114
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53002207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A530020Medicaid
CA00A530020Medicaid
CA00A530020Medicare ID - Type Unspecified