Provider Demographics
NPI:1962635144
Name:PROACTIVE CARE MEDICAL GROUP PA
Entity Type:Organization
Organization Name:PROACTIVE CARE MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-263-2831
Mailing Address - Street 1:5196 MARINER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-1802
Mailing Address - Country:US
Mailing Address - Phone:352-263-2831
Mailing Address - Fax:
Practice Address - Street 1:5196 MARINER BOULEVARD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-1802
Practice Address - Country:US
Practice Address - Phone:352-263-2831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty