Provider Demographics
NPI:1871130732
Name:GONZALO A DIAZ
Entity type:Organization
Organization Name:GONZALO A DIAZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-779-7378
Mailing Address - Street 1:4305 N MESA ST STE B
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-1124
Mailing Address - Country:US
Mailing Address - Phone:915-779-7378
Mailing Address - Fax:915-779-2822
Practice Address - Street 1:1204 MAIN ST NE STE A
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7423
Practice Address - Country:US
Practice Address - Phone:915-779-7378
Practice Address - Fax:915-779-2822
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GONZALO A DIAZ
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-10
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM79570054Medicaid