Healthcare Provider Details

I. General information

NPI: 1255519773
Provider Name (Legal Business Name): MRS. OSVALDO DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3D BATTALION 1ST MAR BATTALION AID STATION BOX 555422
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

234 RANCHO DEL ORO DR APT 100
OCEANSIDE CA
92057-7308
US

V. Phone/Fax

Practice location:
  • Phone: 760-763-0565
  • Fax:
Mailing address:
  • Phone: 760-763-0565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: