Provider Demographics
NPI:1306880836
Name:DIAZ, JOSE J (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:J
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 1:147 W ROUTE 66 # 650
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6208
Mailing Address - Country:US
Mailing Address - Phone:626-524-3865
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:5451 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-2609
Practice Address - Country:US
Practice Address - Phone:909-464-8667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64744207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A647440Medicaid
CAH12668Medicare UPIN
CA00A647440Medicaid
CA00A647442Medicare PIN
CAWA64744Medicare PIN