Provider Demographics
NPI:1497191563
Name:MED-CLINIC INC.
Entity Type:Organization
Organization Name:MED-CLINIC INC.
Other - Org Name:MANUEL LOPEZ DIAZ MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-477-4475
Mailing Address - Street 1:10800 NW 58TH ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2854
Mailing Address - Country:US
Mailing Address - Phone:305-477-4475
Mailing Address - Fax:305-477-4487
Practice Address - Street 1:10800 NW 58 ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178
Practice Address - Country:US
Practice Address - Phone:305-477-4475
Practice Address - Fax:305-477-4487
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MED-CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8690261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG42454Medicare PIN