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NPI Code Detail

MEDICARE: MR. HECTOR DIAZ JR. IDC

MEDICARE: MR. HECTOR DIAZ JR. IDC
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
11710I1002XIndependent Duty Corpsman

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11291997941OTHERDOD ID

General Provider Information

NPI Number : 1063882421
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. HECTOR DIAZ JR. IDC
Provider Business Mailing Address
First Line : 4577 ACACIA AVE APT 7
Second Line :
City : LA MESA
State : CA
Zip : 91941-6478
Country : US
Telephone Number : 619-709-4961
Fax Number :
Provider Business Practice Location Address
First Line : 4577 ACACIA AVE APT 7
Second Line :
City : LA MESA
State : CA
Zip : 91941-6478
Country : US
Telephone Number : 619-709-4961
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/29/2015
Last Update Date : 09/29/2015

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