Healthcare Provider Details

I. General information

NPI: 1962819573
Provider Name (Legal Business Name): JACQUELINE VANESSA REYES DIAZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3533 S ALAMEDA ST APT 532
CORPUS CHRISTI TX
78411-1721
US

IV. Provider business mailing address

3533 S ALAMEDA ST
CORPUS CHRISTI TX
78411-1721
US

V. Phone/Fax

Practice location:
  • Phone: 361-694-4864
  • Fax: 361-851-6867
Mailing address:
  • Phone: 631-575-4180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number080216
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberT2737
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: