Provider Demographics
NPI:1780941443
Name:DIAZ, GILBERTO A (DPT)
Entity type:Individual
Prefix:
First Name:GILBERTO
Middle Name:A
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17660 UNION TPKE
Mailing Address - Street 2:SUITE 195
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1526
Mailing Address - Country:US
Mailing Address - Phone:718-820-9300
Mailing Address - Fax:
Practice Address - Street 1:17660 UNION TPKE
Practice Address - Street 2:SUITE 195
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1526
Practice Address - Country:US
Practice Address - Phone:718-820-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist