Provider Demographics
NPI:1174071807
Name:JOSE M DIAZ-DIAZ
Entity type:Organization
Organization Name:JOSE M DIAZ-DIAZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIAZ-DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-306-4284
Mailing Address - Street 1:1614 WEAVER DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-3334
Mailing Address - Country:US
Mailing Address - Phone:787-306-4284
Mailing Address - Fax:
Practice Address - Street 1:1614 WEAVER DR
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-3334
Practice Address - Country:US
Practice Address - Phone:787-306-4284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-11
Last Update Date:2016-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122262261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1497792162OtherNPI
PRC82723Medicare UPIN