Provider Demographics
NPI:1396180329
Name:DIAZ, ADISLEY (PD)
Entity Type:Individual
Prefix:
First Name:ADISLEY
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4995 NW 72ND AVE
Mailing Address - Street 2:409
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33166-5643
Mailing Address - Country:US
Mailing Address - Phone:305-599-5258
Mailing Address - Fax:305-599-5259
Practice Address - Street 1:4995 NW 72ND AVE
Practice Address - Street 2:409
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33166-5643
Practice Address - Country:US
Practice Address - Phone:305-599-5258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC9762261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC9762OtherAHCA