Provider Demographics
NPI:1700387578
Name:DIAZ, JOSEPH ANTHONY
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 PELICAN AVE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2908
Mailing Address - Country:US
Mailing Address - Phone:910-574-7366
Mailing Address - Fax:
Practice Address - Street 1:4301 JONES BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-4712
Practice Address - Country:US
Practice Address - Phone:910-574-7366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
171000000XOtherTRICARE