Provider Demographics
NPI:1194118919
Name:CARLOS E.DIAZ
Entity type:Organization
Organization Name:CARLOS E.DIAZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:THEISEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-475-3973
Mailing Address - Street 1:8740 N KENDALL DR
Mailing Address - Street 2:105
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-2212
Mailing Address - Country:US
Mailing Address - Phone:305-270-2080
Mailing Address - Fax:305-270-2012
Practice Address - Street 1:8740 N KENDALL DR
Practice Address - Street 2:105
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2212
Practice Address - Country:US
Practice Address - Phone:305-270-2080
Practice Address - Fax:305-270-2012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00502232080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371110200Medicaid
FL371110200Medicaid