=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194118919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARLOS E.DIAZ
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2015
-----------------------------------------------------
Last Update Date | 03/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8740 N KENDALL DR 105
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33176-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-270-2080
-----------------------------------------------------
Fax | 305-270-2012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8740 N KENDALL DR 105
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33176-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-270-2080
-----------------------------------------------------
Fax | 305-270-2012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNT
-----------------------------------------------------
Name | MRS. ANNA THEISEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-475-3973
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0214X
-----------------------------------------------------
Taxonomy Name | Pediatric Pulmonology Physician
-----------------------------------------------------
License Number | ME0050223
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------