Provider Demographics
NPI:1790997609
Name:R DIAZ MD LLC
Entity Type:Organization
Organization Name:R DIAZ MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:R
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-339-4444
Mailing Address - Street 1:4 BY PASS RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SALEM
Mailing Address - State:NJ
Mailing Address - Zip Code:08079-2053
Mailing Address - Country:US
Mailing Address - Phone:856-339-4444
Mailing Address - Fax:
Practice Address - Street 1:4 BY PASS RD
Practice Address - Street 2:SUITE 203
Practice Address - City:SALEM
Practice Address - State:NJ
Practice Address - Zip Code:08079-2053
Practice Address - Country:US
Practice Address - Phone:856-339-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0310550207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0515302Medicaid
NJC56266Medicare UPIN
NJ0515302Medicaid