Basic Information
| Provider Information | |||||||||
| NPI: | 1376530188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 E DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035938441 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 07/10/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 35.085504 | OH | N | Allopathic & Osteopathic Physicians | General Practice | 207P00000X | N9692 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00966738 | 01 | TX | RAIL ROAD | OTHER | 283196801 | 05 | TX | MEDICAID | 75-2616977-001 | 01 | TX | TRICARE | OTHER | 8DQ153 | 01 | TX | BCBS | OTHER | 283196802 | 05 | TX | MEDICAID | 75-2616977-028 | 01 | TX | TRICARE | OTHER | 8CV291 | 01 | TX | BCBS | OTHER | 283196803 | 05 | TX | MEDICAID | 75-0818167-044 | 01 | TX | TRICARE | OTHER | 75-2616977-002 | 01 | TX | TRICARE | OTHER | 8EZ069 | 01 | TX | BCBS | OTHER | 283196809 | 05 | TX | MEDICAID | 75-0818167-048 | 01 | TX | TRICARE | OTHER | P01464105 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 750818167022 | 01 | TX | TRICARE | OTHER | 8CV290 | 01 | TX | BCBS | OTHER |