Healthcare Provider Details

I. General information

NPI: 1346409802
Provider Name (Legal Business Name): PULMONARY GROUP OF CENTRAL FLORIDA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1038 W NORTH BLVD STE 102
LEESBURG FL
34748
US

IV. Provider business mailing address

1038 W NORTH BLVD STE 102
LEESBURG FL
34748-5077
US

V. Phone/Fax

Practice location:
  • Phone: 352-315-1627
  • Fax: 352-326-8744
Mailing address:
  • Phone: 352-315-1627
  • Fax: 352-326-8744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME94696
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME94696
License Number StateFL

VIII. Authorized Official

Name: JOSE L DIAZ
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 352-315-1627