Healthcare Provider Details

I. General information

NPI: 1700387578
Provider Name (Legal Business Name): JOSEPH ANTHONY DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 08/29/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

200 WEST MERCY CIRCLE
CAMP PENDLETON CA
92055
US

V. Phone/Fax

Practice location:
  • Phone: 910-574-7366
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101268149
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: