Provider Demographics
NPI:1255516274
Name:ROBERT L DIAZ
Entity type:Organization
Organization Name:ROBERT L DIAZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-747-0500
Mailing Address - Street 1:1002 S OLD DIXIE HWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7202
Mailing Address - Country:US
Mailing Address - Phone:561-747-0500
Mailing Address - Fax:561-748-0016
Practice Address - Street 1:1002 S OLD DIXIE HWY
Practice Address - Street 2:SUITE 206
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7202
Practice Address - Country:US
Practice Address - Phone:561-747-0500
Practice Address - Fax:561-748-0016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0014368174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD55712Medicare UPIN
FLK8129Medicare PIN