Provider Demographics
NPI:1396137428
Name:DIAZ, JERRY
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:173 1/2 CORTLANDT ST
Mailing Address - Street 2:
Mailing Address - City:SLEEPY HOLLOW
Mailing Address - State:NY
Mailing Address - Zip Code:10591
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:173 1/2 CORTLANDT ST
Practice Address - Street 2:
Practice Address - City:SLEEPY HOLLOW
Practice Address - State:NY
Practice Address - Zip Code:10591
Practice Address - Country:US
Practice Address - Phone:914-609-8646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator