Provider Demographics
NPI:1174109755
Name:DIAZ, ROBERT MIGUEL (DPT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:MIGUEL
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4728 N 15TH ST APT 142
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-3774
Mailing Address - Country:US
Mailing Address - Phone:520-431-6341
Mailing Address - Fax:
Practice Address - Street 1:12808 N BLACK CANYON HWY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-1346
Practice Address - Country:US
Practice Address - Phone:602-375-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-31686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist