Provider Demographics
NPI:1255311338
Name:LOPEZ DIAZ, MANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:
Last Name:LOPEZ 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 1:3103 SW 156TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4920
Mailing Address - Country:US
Mailing Address - Phone:305-226-7431
Mailing Address - Fax:888-959-7905
Practice Address - Street 1:9333 SW 152ND ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1778
Practice Address - Country:US
Practice Address - Phone:305-256-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0083364207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264971300Medicaid
P00414260OtherRR MCR
FL28010OtherBCBS
FL28010TMedicare PIN
FL264971300Medicaid
FL28010BMedicare PIN
P00414260OtherRR MCR