Provider Demographics
NPI:1679012959
Name:DIAZ, DIANA I
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:I
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:I
Other - Last Name:MEJIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:111 FINDERNE AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-3100
Mailing Address - Country:US
Mailing Address - Phone:908-722-4140
Mailing Address - Fax:
Practice Address - Street 1:111 FINDERNE AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-3100
Practice Address - Country:US
Practice Address - Phone:908-722-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-19
Last Update Date:2017-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00312000225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant