Provider Demographics
NPI:1699008896
Name:DIAZ, OMAR BLAS SR (ARNP)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:BLAS
Last Name:DIAZ
Suffix:SR
Gender:M
Credentials:ARNP
Other - Prefix:DR
Other - First Name:OMAR
Other - Middle Name:B
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP-FNP
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:12995 S CLEVELAND AVE STE 184A
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7703
Practice Address - Country:US
Practice Address - Phone:239-226-2727
Practice Address - Fax:239-939-9876
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008455363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily