Healthcare Provider Details

I. General information

NPI: 1902204514
Provider Name (Legal Business Name): MIDIALA E DIAZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIDIALA E DIAZ-IGLESIAS MD

II. Dates (important events)

Enumeration Date: 12/12/2014
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12376 QUAIL ROOST DR
MIAMI FL
33177
US

IV. Provider business mailing address

6100 BLUE LAGOON DR STE 365
MIAMI FL
33126-7010
US

V. Phone/Fax

Practice location:
  • Phone: 786-623-0994
  • Fax: 786-430-8197
Mailing address:
  • Phone: 786-322-7333
  • Fax: 786-322-7329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number31573R
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME130934
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: