Provider Demographics
NPI:1952303620
Name:DIAZ-GONZALEZ, VICTOR M (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:M
Last Name:DIAZ-GONZALEZ
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 421718
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-4203
Mailing Address - Country:US
Mailing Address - Phone:843-652-8226
Mailing Address - Fax:
Practice Address - Street 1:9653 OCEAN HWY
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-7425
Practice Address - Country:US
Practice Address - Phone:843-235-3131
Practice Address - Fax:843-237-9646
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20052207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT42031Medicaid
SCG604426287Medicare PIN
SC060049731Medicare PIN
SCG60442Medicare UPIN
SCG604425879Medicare PIN