Provider Demographics
NPI:1902204514
Name:DIAZ, MIDIALA E (MD)
Entity Type:Individual
Prefix:MRS
First Name:MIDIALA
Middle Name:E
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MIDIALA
Other - Middle Name:E
Other - Last Name:DIAZ-IGLESIAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6100 BLUE LAGOON DR STE 365
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-7010
Mailing Address - Country:US
Mailing Address - Phone:786-322-7333
Mailing Address - Fax:786-322-7329
Practice Address - Street 1:12376 QUAIL ROOST DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177
Practice Address - Country:US
Practice Address - Phone:786-623-0994
Practice Address - Fax:786-430-8197
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-12
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR31573R282N00000X
FLME130934208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0021581600Medicaid