Healthcare Provider Details

I. General information

NPI: 1083294821
Provider Name (Legal Business Name): CONLEY DIAZ-GOMEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MATTHEW ST
MARIETTA OH
45750-1699
US

IV. Provider business mailing address

401 MATTHEW ST
MARIETTA OH
45750-1635
US

V. Phone/Fax

Practice location:
  • Phone: 740-376-1939
  • Fax: 740-374-1693
Mailing address:
  • Phone: 407-376-1939
  • Fax: 740-374-1693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.151061
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: