MEDICARE: SAM DIASTI MD

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	207R00000X	Internal Medicine Physician	ME71925	FL

General Provider Information

NPI Number	:	1730175944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAM DIASTI MD

Provider Business Mailing Address
First Line	:	2605 W SWANN AVE
Second Line	:	STE. 100
City	:	TAMPA
State	:	FL
Zip	:	33609-4039
Country	:	US
Telephone Number	:	813-874-5500
Fax Number	:	813-874-5505

Provider Business Practice Location Address
First Line	:	2605 W SWANN AVE
Second Line	:	STE. 100
City	:	TAMPA
State	:	FL
Zip	:	33609-4039
Country	:	US
Telephone Number	:	713-874-5500
Fax Number	:	813-874-5505

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

Provider Enumeration Date	:	09/22/2005
Last Update Date	:	12/02/2020

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