Healthcare Provider Details

I. General information

NPI: 1316566912
Provider Name (Legal Business Name): JUAN GABRIEL DIAZ-HERNANDEZ DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11760 SW 40TH ST STE 448
MIAMI FL
33175-3598
US

IV. Provider business mailing address

8200 NW 27TH ST STE 108
DORAL FL
33122-1902
US

V. Phone/Fax

Practice location:
  • Phone: 305-223-9595
  • Fax: 305-229-9596
Mailing address:
  • Phone: 786-662-3893
  • Fax: 786-662-3899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO4448
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: