Healthcare Provider Details

I. General information

NPI: 1578265518
Provider Name (Legal Business Name): MADELINE NICOLE DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 COPPERFIELD BLVD NE
CONCORD NC
28025-2441
US

IV. Provider business mailing address

2120 HELEN DR NW
CONCORD NC
28027-4723
US

V. Phone/Fax

Practice location:
  • Phone: 704-403-0471
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2026-04031
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: