Provider Demographics
NPI:1194314476
Name:DIAZ, LUIS CARLOS (PT, DPT)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:CARLOS
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 ROUTE 9 N STE 410
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-1003
Mailing Address - Country:US
Mailing Address - Phone:201-801-7141
Mailing Address - Fax:
Practice Address - Street 1:323 MARIN BLVD
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-3698
Practice Address - Country:US
Practice Address - Phone:551-222-4520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01987100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist