Provider Demographics
NPI:1508537200
Name:DIAZ, JOSE R
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:R
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7743 SW 86TH ST # D231
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-7285
Mailing Address - Country:US
Mailing Address - Phone:786-319-3441
Mailing Address - Fax:
Practice Address - Street 1:7743 SW 86TH ST # D231
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-7285
Practice Address - Country:US
Practice Address - Phone:786-319-3441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-120421106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108257600Medicaid