Basic Information
| Provider Information | |||||||||
| NPI: | 1255697009 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | DANIELA | ||||||||
| MiddleName: | CRISTINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 165 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OSSINING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105624702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149411263 | ||||||||
| FaxNumber: | 9149418626 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BREWSTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105091521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452796999 | ||||||||
| FaxNumber: | 8452790908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2012 | ||||||||
| LastUpdateDate: | 02/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 279079 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04195740 | 05 | NY | MEDICAID |