Basic Information
| Provider Information | |||||||||
| NPI: | 1871577098 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | JANET | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 W HUNTING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073008 | ||||||||
| FaxNumber: | 2157071387 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 E ALLEGHENY AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191344427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159263700 | ||||||||
| FaxNumber: | 2159263702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD053874L | PA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 001597753 | 05 | PA | MEDICAID | 160032946 | 01 | PA | RAILROAD MEDICARE | OTHER | 885573 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 1041943 | 01 | PA | KMHP | OTHER | 519064 | 01 | PA | COVENTRY HEALTH AMERICA | OTHER | 0013242000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 0581982 | 01 | PA | AETNA HMO | OTHER | 2013029 | 01 | PA | UNITED HEALTHCARE | OTHER | CD4829 | 01 | PA | RAILROAD MEDICARE GROUP TPI | OTHER | 0159775307 | 01 | PA | AMERICHOICE | OTHER | 597586 | 01 | PA | MEDICARE GROUP TPI | OTHER | 2891 | 01 | PA | BRAVO HEALTH | OTHER | 2Y3095 | 01 | PA | HEALTH NET | OTHER | 5723452 | 01 | PA | AETNA PPO | OTHER | P416865 | 01 | PA | OXFORD | OTHER |