=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518186469
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANUEL DIEZ, M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 E BROWARD BLVD STE 608
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33301-2029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-462-8030
-----------------------------------------------------
Fax | 954-462-8090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 E BROWARD BLVD STE 608
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33301-2029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-462-8030
-----------------------------------------------------
Fax | 954-462-8090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MANUEL J DIEZ LOPEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 954-462-8030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME27360
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------