Provider Demographics
NPI:1700071529
Name:REX GALAM DIAZ
Entity Type:Organization
Organization Name:REX GALAM DIAZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REX
Authorized Official - Middle Name:GALAM
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:757-673-8562
Mailing Address - Street 1:612 KINGSBOROUGH SQ STE 202
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-5054
Mailing Address - Country:US
Mailing Address - Phone:757-673-8562
Mailing Address - Fax:
Practice Address - Street 1:612 KINGSBOROUGH SQ SUITE 202
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320
Practice Address - Country:US
Practice Address - Phone:757-673-8562
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300814213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010135729Medicaid
VAVAA102838Medicare PIN
VAY28030Medicare UPIN