MEDICARE: MS. GLORIA ISABEL DIAZ MD

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	207RG0100X	Gastroenterology Physician		IL

General Provider Information

NPI Number	:	1639168222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GLORIA ISABEL DIAZ MD

Provider Business Mailing Address
First Line	:	2805 N KNOXVILLE AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61604-2869
Country	:	US
Telephone Number	:	309-624-9400
Fax Number	:	309-624-2280

Provider Business Practice Location Address
First Line	:	2805 N KNOXVILLE AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61604-2869
Country	:	US
Telephone Number	:	309-624-9400
Fax Number	:	309-624-2280

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

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	07/08/2007

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