Healthcare Provider Details

I. General information

NPI: 1124221593
Provider Name (Legal Business Name): KEYLA DIAZ - MEDINA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W COMMERCIAL BLVD STE 20
FORT LAUDERDALE FL
33309-3334
US

IV. Provider business mailing address

PO BOX 25487
SARASOTA FL
34277-2487
US

V. Phone/Fax

Practice location:
  • Phone: 954-368-4560
  • Fax:
Mailing address:
  • Phone: 941-216-0072
  • Fax: 877-807-0253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1152
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number14586
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: