Basic Information
| Provider Information | |||||||||
| NPI: | 1952301038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | JOSE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5900 BYRON CENTER AVE SW | ||||||||
| Address2: | MEDICAL ADMINISTRATION | ||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162523243 | ||||||||
| FaxNumber: | 6162520260 | ||||||||
| Practice Location | |||||||||
| Address1: | 2122 HEALTH DR SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162525950 | ||||||||
| FaxNumber: | 6162525956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 12/08/2017 | ||||||||
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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 | 174400000X | 203831 | MA | N | Other Service Providers | Specialist | 207RC0000X | ME93966 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 4301097454 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 4301097454 | 01 | MI | STATE LICENSE | OTHER |