Healthcare Provider Details

I. General information

NPI: 1841823630
Provider Name (Legal Business Name): TAHYRI DIAZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAHYRI DIAZ SUJO

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 W BURLINGTON AVE STE 100
LA GRANGE IL
60525-2234
US

IV. Provider business mailing address

POB 7132960
CHICAGO IL
60677-1260
US

V. Phone/Fax

Practice location:
  • Phone: 708-579-4801
  • Fax: 708-579-4805
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number831764
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number831764
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-180988
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number831764
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.082431
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code163WX1500X
TaxonomyOstomy Care Registered Nurse
License Number831764
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: