Provider Demographics
NPI:1780189902
Name:DIEHL, IZADORA IZIDORO (MD)
Entity Type:Individual
Prefix:
First Name:IZADORA
Middle Name:IZIDORO
Last Name:DIEHL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IZADORA
Other - Middle Name:PORTO
Other - Last Name:IZIDORO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3065 DANIELS RD # 1138
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-7002
Mailing Address - Country:US
Mailing Address - Phone:770-375-7568
Mailing Address - Fax:808-427-9892
Practice Address - Street 1:4700 MILLENIA BOULEVARD
Practice Address - Street 2:SUITE 175
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839
Practice Address - Country:US
Practice Address - Phone:770-375-7568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME165428208D00000X
HIMD-21547208D00000X
NC2020-00312208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME165428OtherLICENSE # BY FLORIDA MEDICAL BOARD
HIMD-21547OtherLICENSE # BY HAWAII MEDICAL BOARD
NC2020-00312OtherLICENSE # BY NORTH CAROLINA MEDICAL BOARD