Provider Demographics
NPI:1659318608
Name:DIAZ, JOSE L (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:L
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 1:1038 W NORTH BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5077
Mailing Address - Country:US
Mailing Address - Phone:352-315-1627
Mailing Address - Fax:352-326-8744
Practice Address - Street 1:1038 W NORTH BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748
Practice Address - Country:US
Practice Address - Phone:352-315-1627
Practice Address - Fax:352-326-8744
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94696207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35150OtherBLUE SHIELD
FL274950500Medicaid
FL35150OtherBLUE SHIELD