Provider Demographics
NPI:1912536350
Name:CORREA, GABRIEL JOSE DIAZ (MD)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:JOSE DIAZ
Last Name:CORREA
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 1:101 NW 46TH TER
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-3150
Mailing Address - Country:US
Mailing Address - Phone:786-337-1019
Mailing Address - Fax:
Practice Address - Street 1:703 N FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1006
Practice Address - Country:US
Practice Address - Phone:954-844-1402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
FL166413208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program