Provider Demographics
NPI:1023478880
Name:LOPEZ DIAZ, TAMARA (MD)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:LOPEZ DIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13795 SW 36TH AVENUE RD STE 4
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34473-6104
Mailing Address - Country:US
Mailing Address - Phone:352-347-5444
Mailing Address - Fax:352-347-3162
Practice Address - Street 1:13795 SW 36TH AVENUE RD STE 4
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34473
Practice Address - Country:US
Practice Address - Phone:352-347-5444
Practice Address - Fax:352-347-3162
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 127189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME 127189OtherFLORIDA BOARD MEDICAL LICENSE