Provider Demographics
NPI:1265068118
Name:DIAZ, THOMAS CHARLTON (DO)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:CHARLTON
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 1:900 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3902
Mailing Address - Country:US
Mailing Address - Phone:817-336-2100
Mailing Address - Fax:
Practice Address - Street 1:2436 S INTERSTATE 35 E STE 336
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-4900
Practice Address - Country:US
Practice Address - Phone:940-484-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-22
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT4345207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine