Healthcare Provider Details

I. General information

NPI: 1053739094
Provider Name (Legal Business Name): JOSE DIAZ DN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2014
Last Update Date: 02/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 N MILWAUKEE AVE
CHICAGO IL
60641-4001
US

IV. Provider business mailing address

3746 W 62ND PL
CHICAGO IL
60629-4019
US

V. Phone/Fax

Practice location:
  • Phone: 773-294-6899
  • Fax:
Mailing address:
  • Phone: 773-294-6899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number181000384
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number01004
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: