Provider Demographics
NPI:1679581763
Name:DIAZ, WILFRED J (PT, DPT, OCS)
Entity type:Individual
Prefix:
First Name:WILFRED
Middle Name:J
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4443 LEVELSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-3753
Mailing Address - Country:US
Mailing Address - Phone:213-399-7052
Mailing Address - Fax:
Practice Address - Street 1:4443 LEVELSIDE AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-3753
Practice Address - Country:US
Practice Address - Phone:213-399-7052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT329262251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic