Healthcare Provider Details

I. General information

NPI: 1831538016
Provider Name (Legal Business Name): ROBERTO JOSE DIAZ BALZAC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7727 LAKE UNDERHILL RD SUITE 115
ORLANDO FL
32822-8224
US

IV. Provider business mailing address

500 WINDERLEY PL SUITE 115
MAITLAND FL
32751-7247
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-8110
  • Fax:
Mailing address:
  • Phone: 407-875-0555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME127423
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: