Healthcare Provider Details

I. General information

NPI: 1740631571
Provider Name (Legal Business Name): BRANDON ALAN DIAZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 12/06/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11760 SW 40TH ST STE 301
MIAMI FL
33175-3595
US

IV. Provider business mailing address

8581 SW 109TH AVE
MIAMI FL
33173-4427
US

V. Phone/Fax

Practice location:
  • Phone: 786-428-1059
  • Fax: 786-428-1062
Mailing address:
  • Phone: 305-505-3836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME164276
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: