Basic Information
| Provider Information | |||||||||
| NPI: | 1790745776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ-GONZALEZ | ||||||||
| FirstName: | VICENTE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3364 BEYER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN YSIDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921731322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196614100 | ||||||||
| FaxNumber: | 6239250745 | ||||||||
| Practice Location | |||||||||
| Address1: | 3125 N DYSART RD | ||||||||
| Address2: | |||||||||
| City: | AVONDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238829161 | ||||||||
| FaxNumber: | 6239250745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 08/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 31532 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RA0000X | 31532 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine | 208000000X | 31532 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 787038 | 05 | AZ | MEDICAID |