Provider Demographics
NPI:1245397413
Name:DIAZ, DENNIS F (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:F
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 1:2864 WELLNESS AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8335
Mailing Address - Country:US
Mailing Address - Phone:386-775-0333
Mailing Address - Fax:386-775-0427
Practice Address - Street 1:2864 WELLNESS AVE STE 200
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8335
Practice Address - Country:US
Practice Address - Phone:386-775-0333
Practice Address - Fax:386-775-0427
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN7966208600000X
FLME107205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277915300Medicaid
FL208600000XOtherTAXONOMY CODE
FL002287400Medicaid
FL002287400Medicaid