Healthcare Provider Details

I. General information

NPI: 1295727675
Provider Name (Legal Business Name): CLEMENTE CAMPOS DIAZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 AVENUE B
RICHWOOD WV
26261-1236
US

IV. Provider business mailing address

75 AVENUE B
RICHWOOD WV
26261-1236
US

V. Phone/Fax

Practice location:
  • Phone: 304-846-2573
  • Fax: 304-846-9562
Mailing address:
  • Phone: 304-846-2573
  • Fax: 304-846-9562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number09181
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: