Provider Demographics
NPI:1134768740
Name:DIAZ DOMINGUEZ, ALEJANDRO (PTA)
Entity type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:
Last Name:DIAZ DOMINGUEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9837 W OKEECHOBEE RD APT 603
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33016-3144
Mailing Address - Country:US
Mailing Address - Phone:786-587-6237
Mailing Address - Fax:
Practice Address - Street 1:1431 NW 13TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-2607
Practice Address - Country:US
Practice Address - Phone:305-640-5326
Practice Address - Fax:786-294-0270
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28970225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant