Provider Demographics
NPI:1780646216
Name:DIAZ, MICHAEL R (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2507
Mailing Address - Country:US
Mailing Address - Phone:315-349-5511
Mailing Address - Fax:315-349-5921
Practice Address - Street 1:510 SOUTH FORTH STREET
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069
Practice Address - Country:US
Practice Address - Phone:315-349-5873
Practice Address - Fax:315-349-5921
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203320207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01665705Medicaid
NYCC4159Medicare ID - Type UnspecifiedUPSTATE
NY01665705Medicaid