Healthcare Provider Details

I. General information

NPI: 1467147850
Provider Name (Legal Business Name): OLIVER DIAZ GOMEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 07/01/2023
Certification Date: 07/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

764 LAKELAND DR
JACKSON MS
39216-4651
US

IV. Provider business mailing address

1204 GREYMONT AVE
JACKSON MS
39202-2155
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-6800
  • Fax:
Mailing address:
  • Phone: 407-968-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT-5115
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: