Provider Demographics
NPI:1720593288
Name:DIAZ, LAURA M (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:FANWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07023-1373
Mailing Address - Country:US
Mailing Address - Phone:908-889-8687
Mailing Address - Fax:
Practice Address - Street 1:346 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:FANWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07023-1373
Practice Address - Country:US
Practice Address - Phone:908-889-8687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10311600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics