MEDICARE: MR. ROLANDO IVAN DIAZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	347C00000X	Private Vehicle	D242729724220	FL

General Provider Information

NPI Number	:	1558218578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROLANDO IVAN DIAZ

Provider Business Mailing Address
First Line	:	610 E CRAWFORD ST
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33805-3734
Country	:	US
Telephone Number	:	863-904-9618
Fax Number	:

Provider Business Practice Location Address
First Line	:	610 E CRAWFORD ST
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33805-3734
Country	:	US
Telephone Number	:	863-904-9618
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2026
Last Update Date	:	03/11/2026

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