Provider Demographics
NPI:1750638813
Name:DIAZ, ELVIA GUADALUPE (COTA)
Entity Type:Individual
Prefix:
First Name:ELVIA
Middle Name:GUADALUPE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9505 FREDERICKSBURG RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-4284
Mailing Address - Country:US
Mailing Address - Phone:210-272-0319
Mailing Address - Fax:210-272-0324
Practice Address - Street 1:9505 FREDERICKSBURG RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-4284
Practice Address - Country:US
Practice Address - Phone:210-272-0319
Practice Address - Fax:210-272-0324
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200586172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker