Provider Demographics
NPI:1700835451
Name:DIAZ, GERVACIO D III (MD)
Entity Type:Individual
Prefix:DR
First Name:GERVACIO
Middle Name:D
Last Name:DIAZ
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2013 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2405
Mailing Address - Country:US
Mailing Address - Phone:209-529-8506
Mailing Address - Fax:209-529-8524
Practice Address - Street 1:2013 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2405
Practice Address - Country:US
Practice Address - Phone:209-529-8506
Practice Address - Fax:209-529-8524
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69801207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH04055Medicare UPIN