Provider Demographics
NPI:1366833295
Name:DIAZ, ABRAHAM
Entity type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6151 DEW DR STE 300
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-3912
Mailing Address - Country:US
Mailing Address - Phone:915-587-4081
Mailing Address - Fax:
Practice Address - Street 1:1891 N LEE TREVINO DR STE 700
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4129
Practice Address - Country:US
Practice Address - Phone:915-593-3787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1255236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160454801Medicaid
TX160454801Medicaid