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General NPI Number Information
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NPI Number | 1972859767
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Entity Type | Individual
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Provider Name | IVAN RAFAEL MATOS DIAZ M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/30/2012
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Last Update Date | 01/30/2025
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Provider Practice Location Address
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Address Line | 800 E 28TH ST
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City | MINNEAPOLIS
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State | MN
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Zip | 55407-3723
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Country | US
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Telephone | 612-863-3200
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Fax | 612-863-2837
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Provider Business Mailing Address
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Address Line | 2925 CHICAGO AVE
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City | MINNEAPOLIS
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State | MN
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Zip | 55407-1321
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Country | US
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Telephone | 612-262-9000
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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 | 2084V0102X
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Taxonomy Name | Vascular Neurology Physician
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License Number | 61825
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 2084V0102X
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Taxonomy Name | Vascular Neurology Physician
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License Number | ME156611
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 61825
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License Number State | MN
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