Provider Demographics
NPI:1801941281
Name:DIAZ, RUTH BAUTISTA (MD)
Entity type:Individual
Prefix:DR
First Name:RUTH
Middle Name:BAUTISTA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:B
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:45 E LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MI
Mailing Address - Zip Code:48160-1119
Mailing Address - Country:US
Mailing Address - Phone:734-439-2303
Mailing Address - Fax:734-439-0016
Practice Address - Street 1:4870 W CLARK RD
Practice Address - Street 2:SUITE 107
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1104
Practice Address - Country:US
Practice Address - Phone:734-434-7260
Practice Address - Fax:734-434-7607
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2021-09-09
Deactivation Date:2021-08-19
Deactivation Code:
Reactivation Date:2021-09-01
Provider Licenses
StateLicense IDTaxonomies
MI43010354762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA260817222OtherBCBSM
MI035476Medicare UPIN
MI0817222Medicare ID - Type UnspecifiedPROVIDER I. D. #