Provider Demographics
NPI:1891141446
Name:DIAZ, DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
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 1:3016 W CHARLESTON BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1963
Mailing Address - Country:US
Mailing Address - Phone:702-780-2312
Mailing Address - Fax:702-895-4014
Practice Address - Street 1:1524 PINTO LN FL 2
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4195
Practice Address - Country:US
Practice Address - Phone:702-992-6888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A16032207Q00000X
NVDO2581207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVDO2581OtherLICENSE