=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770991739
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIEGO J BOUZAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2014
-----------------------------------------------------
Last Update Date | 09/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5631 SPRING RUN AVE
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-7166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-267-0113
-----------------------------------------------------
Fax | 407-530-0153
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5631 SPRING RUN AVE
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-7166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-267-0113
-----------------------------------------------------
Fax | 407-530-0153
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246XS1301X
-----------------------------------------------------
Taxonomy Name | Sonography Specialist/Technologist Cardiovascular
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------