Provider Demographics
NPI:1568665859
Name:DIAZ, MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name: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 1:1130 NW 64TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4219
Mailing Address - Country:US
Mailing Address - Phone:352-333-5242
Mailing Address - Fax:352-332-7484
Practice Address - Street 1:1130 NW 64TH TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4219
Practice Address - Country:US
Practice Address - Phone:352-333-5242
Practice Address - Fax:352-332-7484
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFLME0062181207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFLME0062181OtherWORKERS COMPENSATION
FL371538800Medicaid
FL18296ZMedicare ID - Type Unspecified
FL371538800Medicaid
FL18296YMedicare PIN