Provider Demographics
NPI:1952582710
Name:DIAZ, ANTONIO MANUEL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:MANUEL
Last Name:DIAZ
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ANTONIO
Other - Middle Name:MANUEL
Other - Last Name:DIAZ
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD, PA
Mailing Address - Street 1:P.O. BOX 4119
Mailing Address - Street 2:864 CENTRAL BLVD. SUITE 100
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520
Mailing Address - Country:US
Mailing Address - Phone:956-541-5231
Mailing Address - Fax:956-541-3230
Practice Address - Street 1:864 CENTRAL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520
Practice Address - Country:US
Practice Address - Phone:956-541-5231
Practice Address - Fax:956-541-3230
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE5508207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116040001Medicaid
TX00T803Medicare UPIN