Healthcare Provider Details

I. General information

NPI: 1215908371
Provider Name (Legal Business Name): DENIS MANUEL DIAZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 06/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1765 DAVID WALKER DR
TAVARES FL
32778-5745
US

IV. Provider business mailing address

1765 DAVID WALKER DR
TAVARES FL
32778-5745
US

V. Phone/Fax

Practice location:
  • Phone: 352-343-3330
  • Fax:
Mailing address:
  • Phone: 352-343-3330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101235887
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009-00227
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME118501
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: