Provider Demographics
NPI:1790727949
Name:DIAZ, JAIME ALONSO (MD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:ALONSO
Last Name: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:PO BOX 60041
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-6041
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:4929 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1702
Practice Address - Country:US
Practice Address - Phone:818-907-4570
Practice Address - Fax:818-907-2814
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88200207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A882000Medicaid
CAWA88200BMedicare PIN
CA00A882000Medicare PIN
CA00A882000Medicaid