Provider Demographics
NPI:1730539602
Name:DIAZ, SANDRA (DO)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:N
Other - Last Name:LUCIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:100A HAVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-4251
Mailing Address - Country:US
Mailing Address - Phone:978-682-5276
Mailing Address - Fax:978-688-4932
Practice Address - Street 1:100A HAVERHILL ST
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-4251
Practice Address - Country:US
Practice Address - Phone:978-682-5276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2875202084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBP10057634OtherPHYSICIAN IN TRAINING PERMIT