Provider Demographics
NPI:1124211636
Name:DIAZ, JOSE LUIS (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GLEN ROYAL PKWY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-5287
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 GLEN ROYAL PKWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-5287
Practice Address - Country:US
Practice Address - Phone:855-226-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0056066207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064065400Medicaid
FL064065400Medicaid
FLE66417Medicare UPIN