MEDICARE: MR. JOSEPH LINCOLN DIAZ JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374700000X	Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1125287944	OTHER		TRICARE

General Provider Information

NPI Number	:	1447916960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSEPH LINCOLN DIAZ JR.

Provider Business Mailing Address
First Line	:	2001 VICTOR WHARF ACCESS RD
Second Line	:
City	:	PEARL CITY
State	:	HI
Zip	:	96782-3400
Country	:	US
Telephone Number	:	808-474-2532
Fax Number	:	808-474-9495

Provider Business Practice Location Address
First Line	:	2001 VICTOR WHARF ACCESS RD
Second Line	:
City	:	PEARL CITY
State	:	HI
Zip	:	96782-3400
Country	:	US
Telephone Number	:	808-474-2532
Fax Number	:	808-474-9495

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2021
Last Update Date	:	11/09/2021

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