Healthcare Provider Details

I. General information

NPI: 1164535753
Provider Name (Legal Business Name): JOSE JUAN DIAZ DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3308 NE 34TH ST
FT LAUDERDALE FL
33308
US

IV. Provider business mailing address

3308 NE 34TH ST
FT LAUDERDALE FL
33308-6906
US

V. Phone/Fax

Practice location:
  • Phone: 954-564-3200
  • Fax: 954-663-9188
Mailing address:
  • Phone: 954-564-3200
  • Fax: 954-663-9188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberOS9686
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOS9686
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: