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General NPI Number Information
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NPI Number | 1801090329
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Entity Type | Individual
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Provider Name | WANDA I. DIAZ M.D.
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Gender | Female
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Dates
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Enumeration Date | 06/11/2007
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Last Update Date | 10/01/2012
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Provider Practice Location Address
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Address Line | 1902 E GORE BLVD
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City | LAWTON
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State | OK
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Zip | 73501-6102
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Country | US
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Telephone | 580-357-4200
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Fax |
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Provider Business Mailing Address
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Address Line | 1902 E GORE BLVD
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City | LAWTON
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State | OK
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Zip | 73501-6102
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Country | US
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Telephone | 580-357-4200
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 038217
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 27633
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License Number State | OK
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