Basic Information
| Provider Information | |||||||||
| NPI: | 1982374120 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | IAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11200 SW 8TH ST # 3-342 | ||||||||
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| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331992516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053487747 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3501 JOHNSON ST | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330215421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549872000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2021 | ||||||||
| LastUpdateDate: | 09/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.