Provider Demographics
NPI:1669937900
Name:ROMAN DIAZ, JOPHIEL IAN
Entity type:Individual
Prefix:
First Name:JOPHIEL
Middle Name:IAN
Last Name:ROMAN DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 BRADLEY DR
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-5251
Mailing Address - Country:US
Mailing Address - Phone:787-616-8584
Mailing Address - Fax:
Practice Address - Street 1:1428 BRADLEY DR
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-5251
Practice Address - Country:US
Practice Address - Phone:787-616-8584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer