Provider Demographics
NPI:1992303192
Name:DIAZ, REUBEN ZETH (PTA)
Entity type:Individual
Prefix:
First Name:REUBEN
Middle Name:ZETH
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12511 OLD GLORY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-6334
Mailing Address - Country:US
Mailing Address - Phone:210-954-1552
Mailing Address - Fax:
Practice Address - Street 1:305 NE LOOP 820
Practice Address - Street 2:BUSINESS TOWER 1, SUITE 200
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053
Practice Address - Country:US
Practice Address - Phone:817-292-8787
Practice Address - Fax:817-789-6849
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2143206225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant