Provider Demographics
NPI:1790192672
Name:RUIZ DIAZ, JUAN CARLOS RUBEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN CARLOS
Middle Name:RUBEN
Last Name:RUIZ DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 RHINELANDER AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1339
Mailing Address - Country:US
Mailing Address - Phone:718-502-1894
Mailing Address - Fax:
Practice Address - Street 1:3098 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8938
Practice Address - Country:US
Practice Address - Phone:573-778-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-12
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290770207R00000X
MO2021036284207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine