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General NPI Number Information
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NPI Number | 1053339135
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Entity Type | Individual
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Provider Name | ANTONIO R DIAZ JR. M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/17/2006
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Last Update Date | 08/19/2021
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Provider Practice Location Address
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Address Line | 174 LMAH CENTER RD
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City | LOGAN
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State | WV
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Zip | 25601-4058
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Country | US
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Telephone | 304-792-7130
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 176
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City | LOGAN
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State | WV
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Zip | 25601-0176
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Country | US
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Telephone | 304-792-7130
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 16814
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License Number State | WV
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