Provider Demographics
NPI:1669633624
Name:BLYTHE, DIANA K
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:K
Last Name:BLYTHE
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 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:305-436-1563
Mailing Address - Fax:305-436-1564
Practice Address - Street 1:9655 NW 41ST ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2973
Practice Address - Country:US
Practice Address - Phone:305-436-1563
Practice Address - Fax:305-436-1564
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC128729208000000X
FLME104378208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110358200Medicaid