Provider Demographics
NPI:1124579974
Name:TAMARA LOPEZ DIAZ, MD. PA
Entity Type:Organization
Organization Name:TAMARA LOPEZ DIAZ, MD. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-278-1337
Mailing Address - Street 1:12301 SE US HIGHWAY 441 STE C
Mailing Address - Street 2:
Mailing Address - City:BELLEVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:34420-4578
Mailing Address - Country:US
Mailing Address - Phone:352-327-8106
Mailing Address - Fax:
Practice Address - Street 1:12301 SE US HIGHWAY 441 STE C
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420
Practice Address - Country:US
Practice Address - Phone:352-327-8106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME127189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty