Healthcare Provider Details

I. General information

NPI: 1164599825
Provider Name (Legal Business Name): GUSTAVO ADOLFO DIAZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 N SECTION ST STE 5
FAIRHOPE AL
36532-2650
US

IV. Provider business mailing address

17026 CARLTON WAY RD
HUNTERSVILLE NC
28078
US

V. Phone/Fax

Practice location:
  • Phone: 251-517-5050
  • Fax: 251-517-5049
Mailing address:
  • Phone: 251-753-2209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number25353
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberME103280
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number02055
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: