Healthcare Provider Details

I. General information

NPI: 1003737883
Provider Name (Legal Business Name): JESUS LEON DIAZ PTCB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 E 81ST ST
TULSA OK
74137-4232
US

IV. Provider business mailing address

122 N NOGALES AVE
TULSA OK
74127-8710
US

V. Phone/Fax

Practice location:
  • Phone: 918-488-8791
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number32788
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: