Healthcare Provider Details

I. General information

NPI: 1487291357
Provider Name (Legal Business Name): GONZALO A DIAZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 GOLF COURSE RD SE
RIO RANCHO NM
87124-4704
US

IV. Provider business mailing address

4305 N MESA ST STE B
EL PASO TX
79902-1124
US

V. Phone/Fax

Practice location:
  • Phone: 915-779-7378
  • Fax: 915-779-2822
Mailing address:
  • Phone: 915-779-7378
  • Fax: 915-779-2822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: GONZALO A DIAZ
Title or Position: OWNER
Credential: MD
Phone: 915-779-7378