Basic Information
| Provider Information | |||||||||
| NPI: | 1962958397 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHAEL DIAZ M.D. P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1513 S HARBOR CITY BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329014681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219512639 | ||||||||
| FaxNumber: | 3219140938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2016 | ||||||||
| LastUpdateDate: | 09/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | DIAZ | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3219512639 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.