Provider Demographics
NPI:1912918400
Name:DIAZ, ROBERTO R (MD)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:R
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 1:4 BYPASS RD
Mailing Address - Street 2:STE 203
Mailing Address - City:SALEM
Mailing Address - State:NJ
Mailing Address - Zip Code:08079
Mailing Address - Country:US
Mailing Address - Phone:856-339-4444
Mailing Address - Fax:856-339-9437
Practice Address - Street 1:4 BYPASS RD
Practice Address - Street 2:STE 203
Practice Address - City:SALEM
Practice Address - State:NJ
Practice Address - Zip Code:08079
Practice Address - Country:US
Practice Address - Phone:856-339-4444
Practice Address - Fax:856-339-9437
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0310550207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0515302Medicaid
085525Medicare ID - Type Unspecified
NJ0515302Medicaid