Provider Demographics
NPI:1972915411
Name:DIAZ, ELISA MARIA (DO)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:MARIA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 SE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-2603
Mailing Address - Country:US
Mailing Address - Phone:631-745-5001
Mailing Address - Fax:
Practice Address - Street 1:46 FAIRVIEW AVE # 111
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976
Practice Address - Country:US
Practice Address - Phone:207-474-0905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS14951207Q00000X
390200000X
MEDO2761207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program