Basic Information
| Provider Information | |||||||||
| NPI: | 1508803693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | HUMBERTO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64834 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816573 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 MEDICAL PKWY | ||||||||
| Address2: | ACP 4TH FLOOR/SURGICAL HOSPITALIST STE. | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434811372 | ||||||||
| FaxNumber: | 4434811360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 09/17/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | D0022049 | MD | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4071161 | 01 | AETNA PPO | OTHER | 6718667 | 01 | AETNA HMO | OTHER | 89468104 | 01 | CAREFIRST | OTHER | K585007 | 01 | CAREFIRST | OTHER | 145726104 | 01 | FEDERAL DEPT OF LABOR (WORKMAN'S COMP) | OTHER | 112414 | 01 | KAISER PERMANENTE | OTHER |