Provider Demographics
NPI:1295703437
Name:EAR,NOSE AND THROAT SPECIALISTS,PC
Entity type:Organization
Organization Name:EAR,NOSE AND THROAT SPECIALISTS,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-696-5510
Mailing Address - Street 1:1206 W SHERMAN AVE
Mailing Address - Street 2:SUITE B2
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-6916
Mailing Address - Country:US
Mailing Address - Phone:856-696-5510
Mailing Address - Fax:856-696-5590
Practice Address - Street 1:1206 W SHERMAN AVE STE 2B
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6911
Practice Address - Country:US
Practice Address - Phone:856-696-5510
Practice Address - Fax:856-696-5590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04900200174400000X
207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ01000270500OtherAMERICHOICE
NJ5281300Medicaid
NJ0466509000OtherAMERIHEALTH
NJ1079307OtherHORIZON NJ HEALTH
NJ5281300Medicaid
NJ572317Medicare ID - Type Unspecified
NJ0466509000OtherAMERIHEALTH