Provider Demographics
NPI:1386367852
Name:DIAZ, ABRAHAM ISAAC
Entity type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:ISAAC
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:TUSCOLA
Mailing Address - State:IL
Mailing Address - Zip Code:61953-1211
Mailing Address - Country:US
Mailing Address - Phone:217-460-1394
Mailing Address - Fax:
Practice Address - Street 1:1203 EGYPTIAN TRL
Practice Address - Street 2:
Practice Address - City:TUSCOLA
Practice Address - State:IL
Practice Address - Zip Code:61953-2050
Practice Address - Country:US
Practice Address - Phone:217-253-4791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003603224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant