Provider Demographics
NPI:1740712017
Name:DIAZ, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
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 1:341 CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-1301
Mailing Address - Country:US
Mailing Address - Phone:914-370-5000
Mailing Address - Fax:
Practice Address - Street 1:341 CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:SCARSDALE
Practice Address - State:NY
Practice Address - Zip Code:10583-1301
Practice Address - Country:US
Practice Address - Phone:914-370-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321127207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology