Provider Demographics
NPI:1063734358
Name:DIAZ, MIGUEL ANGEL (MD)
Entity type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:ANGEL
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MIGUEL
Other - Middle Name:ANGEL
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:61 W GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-3327
Mailing Address - Country:US
Mailing Address - Phone:518-860-9084
Mailing Address - Fax:
Practice Address - Street 1:61 W GLENWOOD DR
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-3327
Practice Address - Country:US
Practice Address - Phone:518-860-9084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-27
Last Update Date:2010-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096118174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist