Healthcare Provider Details

I. General information

NPI: 1487941357
Provider Name (Legal Business Name): MELBA DIAZ REYES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7205 N CORTEZ AVE
TAMPA FL
33614-2638
US

IV. Provider business mailing address

7205 N CORTEZ AVE
TAMPA FL
33614-2638
US

V. Phone/Fax

Practice location:
  • Phone: 813-625-4362
  • Fax:
Mailing address:
  • Phone: 813-625-4362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: