Healthcare Provider Details

I. General information

NPI: 1265630735
Provider Name (Legal Business Name): GLORIA E DIAZ-MEDINA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 SW 60TH COURT SUITE 302
MIAMI FL
33155-3009
US

IV. Provider business mailing address

3200 SW 60TH COURT SUITE 302
MIAMI FL
33155-3009
US

V. Phone/Fax

Practice location:
  • Phone: 305-662-8345
  • Fax: 786-703-7527
Mailing address:
  • Phone: 305-662-8345
  • Fax: 786-703-7527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number26034
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number104466
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number52194
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberME125884
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberP3707
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License NumberP3707
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: