Provider Demographics
NPI:1659713261
Name:NEISA I. DIAZ, M.D., L.L.C.
Entity Type:Organization
Organization Name:NEISA I. DIAZ, M.D., L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NEISA
Authorized Official - Middle Name:I
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-754-7880
Mailing Address - Street 1:13501 ICOT BLVD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-3729
Mailing Address - Country:US
Mailing Address - Phone:727-754-7880
Mailing Address - Fax:727-754-7885
Practice Address - Street 1:13501 ICOT BLVD
Practice Address - Street 2:SUITE 114
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3729
Practice Address - Country:US
Practice Address - Phone:727-754-7880
Practice Address - Fax:727-754-7885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL97050207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277721500Medicaid
FLAD8452Medicare PIN