Healthcare Provider Details

I. General information

NPI: 1093376477
Provider Name (Legal Business Name): JONATHAN DIAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W 11TH ST
PANAMA CITY FL
32401-6304
US

IV. Provider business mailing address

PO BOX 738279
DALLAS TX
75373-8279
US

V. Phone/Fax

Practice location:
  • Phone: 850-785-8557
  • Fax:
Mailing address:
  • Phone: 727-441-1509
  • Fax: 727-474-3726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME173757
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: