Healthcare Provider Details

I. General information

NPI: 1093972143
Provider Name (Legal Business Name): FERNANDO DIAZ MORI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5331 PRIMROSE LAKE CIR STE 112
TAMPA FL
33647-3764
US

IV. Provider business mailing address

10015 SPANISH CHERRY CT
TAMPA FL
33647-3715
US

V. Phone/Fax

Practice location:
  • Phone: 813-651-1085
  • Fax: 813-932-0266
Mailing address:
  • Phone: 941-545-2895
  • Fax: 813-289-6592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME102401
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: