Provider Demographics
NPI:1205632999
Name:DIAZ CORUJO, ILEANA M (MD, PA)
Entity type:Individual
Prefix:DR
First Name:ILEANA
Middle Name:M
Last Name:DIAZ CORUJO
Suffix:
Gender:
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13148 SUMMERTON DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-6259
Mailing Address - Country:US
Mailing Address - Phone:407-912-6078
Mailing Address - Fax:
Practice Address - Street 1:13148 SUMMERTON DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32824-6259
Practice Address - Country:US
Practice Address - Phone:407-912-6078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-22
Last Update Date:2025-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2452363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical