Provider Demographics
NPI:1023335767
Name:HERNAN DIAZ BOLANO MD PA
Entity type:Organization
Organization Name:HERNAN DIAZ BOLANO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HERNAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ BOLANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-394-3429
Mailing Address - Street 1:8200 MILLER DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-5423
Mailing Address - Country:US
Mailing Address - Phone:786-394-3429
Mailing Address - Fax:305-503-8545
Practice Address - Street 1:8600 SW 92ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-7397
Practice Address - Country:US
Practice Address - Phone:786-394-3429
Practice Address - Fax:305-503-8545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL44883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069781800Medicaid