Provider Demographics
NPI:1811908627
Name:DIAZ, ENRIQUE (PT)
Entity type:Individual
Prefix:MR
First Name:ENRIQUE
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:448 E EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-1938
Mailing Address - Country:US
Mailing Address - Phone:408-245-3575
Mailing Address - Fax:408-245-3576
Practice Address - Street 1:448 E EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-1938
Practice Address - Country:US
Practice Address - Phone:408-245-3575
Practice Address - Fax:408-245-3576
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23911225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT239111Medicare ID - Type UnspecifiedPPIN
CAZZZ30166ZMedicare ID - Type UnspecifiedGROUP MEDICARE I.D NUMBER