Provider Demographics
NPI:1780688432
Name:MARTIN, DIANA PATRICIA (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:PATRICIA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:P
Other - Last Name:JEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4403 N ARMENIA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2701
Mailing Address - Country:US
Mailing Address - Phone:813-873-1177
Mailing Address - Fax:813-873-1166
Practice Address - Street 1:4503 N ARMENIA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2745
Practice Address - Country:US
Practice Address - Phone:813-873-1177
Practice Address - Fax:813-873-1166
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2023-10-30
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
FLME88573207KA0200X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268116101Medicaid
FL268116100Medicaid
FLK5769AMedicare PIN
FL268116100Medicaid
FL268116101Medicaid