Provider Demographics
NPI:1770997884
Name:DIAZ, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name: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 1:4401 CAMPUS RIDGE DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6125
Mailing Address - Country:US
Mailing Address - Phone:989-837-9350
Mailing Address - Fax:989-837-9347
Practice Address - Street 1:4401 CAMPUS RIDGE DR STE 1000
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6125
Practice Address - Country:US
Practice Address - Phone:989-837-9350
Practice Address - Fax:989-837-9347
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021186207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine