Provider Demographics
NPI:1780648253
Name:ORTIZ-DIAZ, MIGUEL ANGEL (PA)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:ORTIZ-DIAZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 WASHINGTON STREET
Mailing Address - Street 2:STE 101
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021
Mailing Address - Country:US
Mailing Address - Phone:954-272-2225
Mailing Address - Fax:954-272-0554
Practice Address - Street 1:3702 WASHINGTON STREET
Practice Address - Street 2:STE 101
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021
Practice Address - Country:US
Practice Address - Phone:954-272-2225
Practice Address - Fax:954-272-0554
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101223363A00000X
PA9101223363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P89664Medicare UPIN
FLU0684YMedicare ID - Type Unspecified