Provider Demographics
NPI:1124037312
Name:DIAZ, OLIVER B (MD)
Entity type:Individual
Prefix:MR
First Name:OLIVER
Middle Name:B
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 GOODWIN ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-5807
Mailing Address - Country:US
Mailing Address - Phone:860-589-5593
Mailing Address - Fax:
Practice Address - Street 1:46 GOODWIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5807
Practice Address - Country:US
Practice Address - Phone:860-589-5593
Practice Address - Fax:860-584-0056
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016620207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010016620CT01OtherBLUE SHIELD
CT0192997OtherCIGNA
CT83286OtherU.S. HEALTHCARE
CTP464314OtherOXFORD
CT791603OtherCONNECTICARE
CT500HBX031CT01OtherBLUE CROSS
CT4342196OtherAETNA
CT0016620600OtherBLUE CARE FAMILY
CTOR1837OtherHEALTHNET
CT001166206Medicaid