Provider Demographics
NPI:1730534843
Name:DIAZ, JENNA NATALIA (MD)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:NATALIA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS PL CB 8116
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-3009
Mailing Address - Country:US
Mailing Address - Phone:314-454-6173
Mailing Address - Fax:314-454-2412
Practice Address - Street 1:1 CHILDRENS PL CB 8116
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:314-454-6173
Practice Address - Fax:314-454-2412
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2019017047208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program