Provider Demographics
NPI:1285822924
Name:ROMAN-DIAZ, JAIME LUIS (MD)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:LUIS
Last Name:ROMAN-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:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-432-8500
Mailing Address - Fax:
Practice Address - Street 1:1708 CAPE CORAL PKWY W STE 10
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-6985
Practice Address - Country:US
Practice Address - Phone:239-541-4633
Practice Address - Fax:239-541-1825
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124921207RH0000X, 207RX0202X, 207RH0003X, 207RX0202X
PR17027207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015504400Medicaid