Provider Demographics
NPI:1851452577
Name:DIAZ, NILS M (MD)
Entity Type:Individual
Prefix:
First Name:NILS
Middle Name:M
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 198317
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8317
Mailing Address - Country:US
Mailing Address - Phone:727-734-6635
Mailing Address - Fax:
Practice Address - Street 1:601 MAIN ST
Practice Address - Street 2:MS-417
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-5848
Practice Address - Country:US
Practice Address - Phone:727-734-6635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59531173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374111700Medicaid
FL374111700Medicaid
FL1843UMedicare PIN