Provider Demographics
NPI:1083600092
Name:DIAZ, LUIS C (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:C
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:214 NW PLEASANT GROVE WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3584
Mailing Address - Country:US
Mailing Address - Phone:772-879-0018
Mailing Address - Fax:772-879-0018
Practice Address - Street 1:1796 N HWY 441
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34973
Practice Address - Country:US
Practice Address - Phone:863-763-2151
Practice Address - Fax:863-763-2151
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME88391207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH08727Medicare UPIN