Healthcare Provider Details

I. General information

NPI: 1134129240
Provider Name (Legal Business Name): GONZALO A DIAZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 N MESA ST STE B
EL PASO TX
79902-1124
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 TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberG4109
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberG4109
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: