Provider Demographics
NPI:1164535753
Name:DIAZ, JOSE JUAN (DO)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:JUAN
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 NE 34TH ST
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-6906
Mailing Address - Country:US
Mailing Address - Phone:954-564-3200
Mailing Address - Fax:954-663-9188
Practice Address - Street 1:3308 NE 34TH ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308
Practice Address - Country:US
Practice Address - Phone:954-564-3200
Practice Address - Fax:954-663-9188
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS96862081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I48439Medicare UPIN
FLU6770ZMedicare PIN