MEDICARE: GONZALO A DIAZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RS0012X	Sleep Medicine (Internal Medicine) Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033707179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GONZALO A DIAZ

Provider Business Mailing Address
First Line	:	1016 QUINTA ANTIGUA LN
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-2039
Country	:	US
Telephone Number	:	915-779-7378
Fax Number	:	915-779-2822

Provider Business Practice Location Address
First Line	:	2000 LOMALAND DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79935-2213
Country	:	US
Telephone Number	:	915-875-1801
Fax Number	:	915-875-1516

Authorized Official
Title or Position	:	CLINIC ADMINISTRATOR
Name	:	LILI HERNANDEZ
Credential	:
Telephone Number	:	915-204-6989

Provider Enumeration Date	:	01/05/2021
Last Update Date	:	01/05/2021

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Directions to “GONZALO A DIAZ ” Practice Location

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