Provider Demographics
NPI:1801283916
Name:MARIO A DIAZ-GOMEZ, M.D., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MARIO A DIAZ-GOMEZ, M.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIAZ-GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-303-3074
Mailing Address - Street 1:360 E 7TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6701
Mailing Address - Country:US
Mailing Address - Phone:909-981-2500
Mailing Address - Fax:909-981-2509
Practice Address - Street 1:360 E 7TH ST STE L
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6701
Practice Address - Country:US
Practice Address - Phone:909-303-3074
Practice Address - Fax:909-303-3090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG564320Medicaid
CAG564320Medicaid
CA00G564321Medicare PIN