Basic Information
| Provider Information | |||||||||
| NPI: | 1932654126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ PONCE | ||||||||
| FirstName: | GILBERTO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1321 MURFREESBORO PIKE | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372172626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443597629 | ||||||||
| FaxNumber: | 6155775654 | ||||||||
| Practice Location | |||||||||
| Address1: | 599 FALLING WATERS WAY | ||||||||
| Address2: | |||||||||
| City: | LINDENHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600461703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479167375 | ||||||||
| FaxNumber: | 6155775654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2016 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | 0-19-9861 | FL | Y |
ID Information
| ID | Type | State | Issuer | Description | 019796100 | 05 | FL | MEDICAID |