Healthcare Provider Details

I. General information

NPI: 1609857853
Provider Name (Legal Business Name): MARK ANTHONY DIAZ PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 HEMPSTEAD TPKE
FRANKLIN SQUARE NY
11010-4342
US

IV. Provider business mailing address

820 HEMPSTEAD TPKE
FRANKLIN SQUARE NY
11010-4342
US

V. Phone/Fax

Practice location:
  • Phone: 516-358-8911
  • Fax: 516-358-8960
Mailing address:
  • Phone: 516-358-8911
  • Fax: 516-358-8960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number021050-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: