Provider Demographics
NPI:1932101391
Name:DIAZ, DAVID RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RAY
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 W 16TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2207
Practice Address - Country:US
Practice Address - Phone:317-963-7300
Practice Address - Fax:317-963-7325
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034550A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100126480Medicaid
INCJ7541OtherMEDICARE RR GROUP#
INCJ7541OtherMEDICARE RR GROUP#
E03713Medicare UPIN
191800Medicare PIN
IN191800Medicare PIN