Provider Demographics
NPI:1528835543
Name:DIAZ VALDES, IVAN
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:DIAZ VALDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 HERITAGE WAY
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-1367
Mailing Address - Country:US
Mailing Address - Phone:786-409-9019
Mailing Address - Fax:
Practice Address - Street 1:6376 PINE RIDGE RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-3908
Practice Address - Country:US
Practice Address - Phone:239-348-4221
Practice Address - Fax:239-348-4529
Is Sole Proprietor?:No
Enumeration Date:2023-12-08
Last Update Date:2023-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11030064363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily