Provider Demographics
NPI:1609041276
Name:DIAZ, MAIRA
Entity Type:Individual
Prefix:MRS
First Name:MAIRA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4741 SW 12TH CT
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33317-5605
Mailing Address - Country:US
Mailing Address - Phone:954-325-8176
Mailing Address - Fax:
Practice Address - Street 1:4741 SW 12TH CT
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33317-5605
Practice Address - Country:US
Practice Address - Phone:954-325-8176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker