Provider Demographics
NPI:1417165432
Name:DIAZ, RAFAEL ROBERTO (MDCSA)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:ROBERTO
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MDCSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 270592
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77277-0592
Mailing Address - Country:US
Mailing Address - Phone:713-806-0896
Mailing Address - Fax:
Practice Address - Street 1:11607 BAY LEDGE DR
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8189
Practice Address - Country:US
Practice Address - Phone:173-806-0896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00240363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant