Provider Demographics
NPI:1144459157
Name:DIAZ, WILFREDO ZAULDA
Entity type:Individual
Prefix:
First Name:WILFREDO
Middle Name:ZAULDA
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 W TENNYSON RD APT 264
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-4153
Mailing Address - Country:US
Mailing Address - Phone:575-551-2073
Mailing Address - Fax:
Practice Address - Street 1:2800 BENEDICT DR
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-6840
Practice Address - Country:US
Practice Address - Phone:510-357-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-11
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3696225100000X
TX1196038225100000X
CA291781225100000X
FL29089225100000X
IL070.017161225100000X
IA004432225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist