Provider Demographics
NPI:1467445080
Name:DIAZ, TANYA I (MD)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:I
Last Name:DIAZ
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 1:511 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7326
Mailing Address - Country:US
Mailing Address - Phone:352-728-6808
Mailing Address - Fax:352-728-1743
Practice Address - Street 1:511 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7326
Practice Address - Country:US
Practice Address - Phone:352-728-6808
Practice Address - Fax:352-728-1743
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90760207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270240100Medicaid
FL48179OtherBLUE CROSS BLUE SHIELD
FL270240100Medicaid
FL48179ZMedicare Oscar/Certification
FL48179OtherBLUE CROSS BLUE SHIELD