Provider Demographics
NPI:1831187004
Name:DIAZ, ISMAEL JR (MD)
Entity type:Individual
Prefix:
First Name:ISMAEL
Middle Name:
Last Name:DIAZ
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ISMAEL
Other - Middle Name:
Other - Last Name:DIAZ
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:M D
Mailing Address - Street 1:17903 WEST LAKE HOUSTON PARKWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-3882
Mailing Address - Country:US
Mailing Address - Phone:281-812-1846
Mailing Address - Fax:281-812-2778
Practice Address - Street 1:17903 WEST LAKE HOUSTON PARKWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-3882
Practice Address - Country:US
Practice Address - Phone:281-812-1846
Practice Address - Fax:281-812-2778
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1639230048OtherGROUP NPI
TX1639230048OtherGROUP NPI
TX8F5090Medicare PIN
TXH62967Medicare UPIN