Healthcare Provider Details

I. General information

NPI: 1255464681
Provider Name (Legal Business Name): EMMA EDELMIRA DIAZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5610 W LA SALLE ST
TAMPA FL
33607-1770
US

IV. Provider business mailing address

12008 WANDSWORTH DR
TAMPA FL
33626-2613
US

V. Phone/Fax

Practice location:
  • Phone: 813-287-8998
  • Fax: 813-251-1136
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License NumberME 77657
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: