Basic Information
Provider Information | |||||||||
NPI: | 1578568903 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIAZ | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: | C. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3560 DELAWARE ST | ||||||||
Address2: | 209 | ||||||||
City: | BEAUMONT | ||||||||
State: | TX | ||||||||
PostalCode: | 777063059 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4098993682 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3560 DELAWARE ST | ||||||||
Address2: | 209 | ||||||||
City: | BEAUMONT | ||||||||
State: | TX | ||||||||
PostalCode: | 777063059 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4098993682 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2005 | ||||||||
LastUpdateDate: | 06/25/2010 | ||||||||
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 | 174400000X | L0130 | TX | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 043862401 | 05 | TX |   | MEDICAID |