Provider Demographics
NPI:1255733325
Name:FERNANDO DIEZ, MD
Entity type:Organization
Organization Name:FERNANDO DIEZ, MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:JULIAN
Authorized Official - Last Name:DIEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-261-4119
Mailing Address - Street 1:7805 CORAL WAY STE 102
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-6539
Mailing Address - Country:US
Mailing Address - Phone:305-261-4119
Mailing Address - Fax:305-261-4153
Practice Address - Street 1:7805 CORAL WAY STE 102
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-6539
Practice Address - Country:US
Practice Address - Phone:305-261-4119
Practice Address - Fax:305-261-4153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-20
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME32678208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063464600Medicaid