Basic Information
| Provider Information | |||||||||
| NPI: | 1528025541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ DE LEON | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | OCTAVIO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9002 CULEBRA RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782512873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104373990 | ||||||||
| FaxNumber: | 2104373991 | ||||||||
| Practice Location | |||||||||
| Address1: | 9002 CULEBRA RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782512873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104373990 | ||||||||
| FaxNumber: | 2104373991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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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 | 208000000X | H4825 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 136374903 | 05 | TX | MEDICAID |