Provider Demographics
NPI:1235370289
Name:DIAZ, GERARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:GERARDO
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22112 SW 130TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33170-2694
Mailing Address - Country:US
Mailing Address - Phone:305-978-6309
Mailing Address - Fax:
Practice Address - Street 1:14201 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33176-7224
Practice Address - Country:US
Practice Address - Phone:786-227-6396
Practice Address - Fax:786-227-6456
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-19
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103459208D00000X
FLME 103459208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLID: 138 851 733Medicaid