Healthcare Provider Details

I. General information

NPI: 1508803693
Provider Name (Legal Business Name): MARIO HUMBERTO DIAZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 09/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 MEDICAL PKWY ACP 4TH FLOOR/SURGICAL HOSPITALIST STE.
ANNAPOLIS MD
21401-3280
US

IV. Provider business mailing address

PO BOX 64834
BALTIMORE MD
21264-4834
US

V. Phone/Fax

Practice location:
  • Phone: 443-481-1372
  • Fax: 443-481-1360
Mailing address:
  • Phone: 443-481-6573
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD0022049
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: