Healthcare Provider Details

I. General information

NPI: 1982713210
Provider Name (Legal Business Name): SUSAN M DIAZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PRESBYTERIAN HOSPITAL 1100 CENTRAL AVE SE PMG PEDIATRIC INTENSIVISTS
ALBUQUERQUE NM
87106
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1163
  • Fax: 505-724-7043
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number98-247
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: