MEDICARE: FABIO E SU DIAZ M.D.

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	207Q00000X	Family Medicine Physician	ME73893	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841305752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FABIO E SU DIAZ M.D.

Provider Business Mailing Address
First Line	:	114 N FLAGLER AVE
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33060-6635
Country	:	US
Telephone Number	:	954-786-0691
Fax Number	:	954-783-2969

Provider Business Practice Location Address
First Line	:	114 N FLAGLER AVE
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33060-6635
Country	:	US
Telephone Number	:	954-786-0691
Fax Number	:	954-783-2969

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	06/13/2012

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