Provider Demographics
NPI:1386796258
Name:ANTONIO M. DIAZ JR MDPA INC.
Entity type:Organization
Organization Name:ANTONIO M. DIAZ JR MDPA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ERICKA
Authorized Official - Middle Name:
Authorized Official - Last Name:PARRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-541-5231
Mailing Address - Street 1:P.O. BOX 4119
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78523-4119
Mailing Address - Country:US
Mailing Address - Phone:956-541-5231
Mailing Address - Fax:956-541-3230
Practice Address - Street 1:864 CENTRAL BLVD.
Practice Address - Street 2:STE. #100
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-7551
Practice Address - Country:US
Practice Address - Phone:956-541-5231
Practice Address - Fax:956-541-3230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE5508207Q00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116040001Medicaid
TX1160400-01Medicaid
TX1160400-01Medicaid
TX116040001Medicaid