Provider Demographics
NPI:1376978825
Name:DIAZ, SHONDELL
Entity type:Individual
Prefix:
First Name:SHONDELL
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 SE CESAR CHAVEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1704
Mailing Address - Country:US
Mailing Address - Phone:206-785-1015
Mailing Address - Fax:206-785-1023
Practice Address - Street 1:3705 SE CESAR CHAVEZ BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1704
Practice Address - Country:US
Practice Address - Phone:206-785-1015
Practice Address - Fax:206-785-1023
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA1648462084A0401X, 363A00000X, 363AM0700X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical