Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 4301067020 | MI |
N | 208D00000X | General Practice Physician | 6136 | PR |
NPI | 1033150230 |
---|---|
Provider Name | Dr. Leonora Diaz |
First Address | Kentwood, MI 49512-8412 |
Second Address | Kentwood, MI 49512-8412 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2006 |
Last Update Date | 30/03/2021 |