Provider Demographics
NPI:1972859767
Name:MATOS DIAZ, IVAN RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:RAFAEL
Last Name:MATOS 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 198054
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8054
Mailing Address - Country:US
Mailing Address - Phone:786-596-3876
Mailing Address - Fax:
Practice Address - Street 1:8950 N KENDALL DR STE 407W
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2132
Practice Address - Country:US
Practice Address - Phone:786-596-3876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1566112084V0102X
MN618252084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology