Provider Demographics
NPI:1578296844
Name:DIAZ MEDINA, GWENDOLYN (MD)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:DIAZ MEDINA
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 1:2262 CHATHAM PLACE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-4766
Mailing Address - Country:US
Mailing Address - Phone:407-267-8203
Mailing Address - Fax:
Practice Address - Street 1:833 E OAK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5838
Practice Address - Country:US
Practice Address - Phone:844-665-4827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR023427208D00000X
FL1571207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice