Provider Demographics
NPI:1780685578
Name:DIAZ, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1330
Mailing Address - Country:US
Mailing Address - Phone:228-864-4392
Mailing Address - Fax:228-868-7103
Practice Address - Street 1:14231 SEAWAY RD STE 5003
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4660
Practice Address - Country:US
Practice Address - Phone:228-864-4392
Practice Address - Fax:228-868-7103
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS134332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00155062Medicaid
MS00155062Medicaid
MSF156877Medicare UPIN