Provider Demographics
NPI:1225424740
Name:DIAZ, LISA MARIE (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:352-567-0188
Mailing Address - Fax:813-355-5101
Practice Address - Street 1:17401 COMMERCE PARK BLVD STE 104
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3507
Practice Address - Country:US
Practice Address - Phone:813-751-0777
Practice Address - Fax:813-377-1727
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS13514207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program