Provider Demographics
NPI:1902879281
Name:DIAZ, ANTONIO S (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:S
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10802-0366
Mailing Address - Country:US
Mailing Address - Phone:914-771-7335
Mailing Address - Fax:914-771-7338
Practice Address - Street 1:1250 WATERS PL
Practice Address - Street 2:SUITE 507
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2720
Practice Address - Country:US
Practice Address - Phone:718-792-4500
Practice Address - Fax:718-792-4502
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196305207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01752547Medicaid
F95545Medicare UPIN
NY94J611Medicare ID - Type Unspecified