=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245397413
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENNIS F. DIAZ M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2007
-----------------------------------------------------
Last Update Date | 01/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2864 WELLNESS AVE STE 200
-----------------------------------------------------
City | ORANGE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32763-8335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-775-0333
-----------------------------------------------------
Fax | 386-775-0427
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2864 WELLNESS AVE STE 200
-----------------------------------------------------
City | ORANGE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32763-8335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-775-0333
-----------------------------------------------------
Fax | 386-775-0427
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | TRN7966
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | ME107205
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------