MEDICARE: LISA MARIE DIAZ D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207N00000X	Dermatology Physician	OS13514	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225424740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE DIAZ D.O.

Provider Business Mailing Address
First Line	:	38135 MARKET SQ
Second Line	:
City	:	ZEPHYRHILLS
State	:	FL
Zip	:	33542-7505
Country	:	US
Telephone Number	:	352-567-0188
Fax Number	:	813-355-5101

Provider Business Practice Location Address
First Line	:	17401 COMMERCE PARK BLVD STE 104
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3507
Country	:	US
Telephone Number	:	813-751-0777
Fax Number	:	813-377-1727

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2015
Last Update Date	:	08/25/2021

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