Provider Demographics
NPI:1265630735
Name:DIAZ-MEDINA, GLORIA E (MD)
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:E
Last Name:DIAZ-MEDINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 SW 60TH COURT
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3009
Mailing Address - Country:US
Mailing Address - Phone:305-662-8345
Mailing Address - Fax:786-703-7527
Practice Address - Street 1:3200 SW 60TH COURT
Practice Address - Street 2:SUITE 302
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3009
Practice Address - Country:US
Practice Address - Phone:305-662-8345
Practice Address - Fax:786-703-7527
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR26034208000000X
MN1044662084N0400X
MN521942084N0400X
TXP37072084N0402X
FLME1258842084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN130001468Medicare PIN
MN130001468Medicare PIN
IAENROLLEDMedicaid