MEDICARE: MR. DERICK TARIQ DIAZ

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1750230488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DERICK TARIQ DIAZ

Provider Business Mailing Address
First Line	:	623 N RICHMOND AVE
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67203-5008
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	623 N RICHMOND AVE
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67203-5008
Country	:	US
Telephone Number	:	316-928-9782
Fax Number	:	316-928-9782

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

Provider Enumeration Date	:	01/26/2026
Last Update Date	:	01/26/2026

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