Provider Demographics
NPI:1366556706
Name:DIAZ, BART MATTHEW (DO)
Entity type:Individual
Prefix:
First Name:BART
Middle Name:MATTHEW
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 N F AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1920
Mailing Address - Country:US
Mailing Address - Phone:520-364-6852
Mailing Address - Fax:520-364-4261
Practice Address - Street 1:155 CALLE PORTAL SUITE 300
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607
Practice Address - Country:US
Practice Address - Phone:520-459-3011
Practice Address - Fax:520-364-4261
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007912207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYVAD000Medicare UPIN