Provider Demographics
NPI:1053339135
Name:DIAZ, ANTONIO R JR (MD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:R
Last Name:DIAZ
Suffix:JR
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:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-0176
Mailing Address - Country:US
Mailing Address - Phone:304-792-7130
Mailing Address - Fax:
Practice Address - Street 1:174 LMAH CENTER RD
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-4058
Practice Address - Country:US
Practice Address - Phone:304-792-7130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV168142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0288291Medicaid
WV1493983OtherUMWA
WV550751751OtherBLUE CROSS/BLUE SHIELD
KY64940489Medicaid
000706447OtherBLUE CROSS/BLUE SHIELD
WV0115148000Medicaid
WV0115148000Medicaid