Healthcare Provider Details

I. General information

NPI: 1316674591
Provider Name (Legal Business Name): OSVALDO DIAZ LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2022
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date: 03/20/2026
Reactivation Date: 04/28/2026

III. Provider practice location address

700 FREDERICK ST STE 103S
SANTA CRUZ CA
95062-2239
US

IV. Provider business mailing address

700 FREDERICK ST STE 103S
SANTA CRUZ CA
95062-2239
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax: 619-374-7134
Mailing address:
  • Phone: 855-223-7123
  • Fax: 619-374-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: