# CALIXTO J CORNAVACA DIAZ MD LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Cornavaca Clinic
- **Organization subpart:** No

## Provider details

- **NPI number:** 1487140349
- **Authorized official:** MRS. SPRING CORNAVACA (BUSINESS ADMINISTRATOR)
- **Authorized official phone:** (470) 892-6607

## Contact information

- **Practice address:** 578 S ENOTA DR NE STE C, GAINESVILLE, GA 30501-8947
- **Practice address phone:** (470) 892-6607
- **Practice address fax:** (470) 290-8474
- **Mailing address:** 578 S ENOTA DR NE STE C, GAINESVILLE, GA 30501-8947
- **Mailing address phone:** (470) 892-6607
- **Mailing address fax:** (470) 290-8474

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | 028490 | GA | — |
| 208D00000X | General Practice Physician | 74951 | GA | Yes |

## Other

- **Enumeration date:** 07/03/2018
- **Last updated:** 07/03/2018

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1326381625 | — | TN |
| 05 | — | 1417990334 | — | GA |