Provider Demographics
NPI:1265667364
Name:DIAZ, MICHELLE L (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:MIHALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3316 3RD ST S
Mailing Address - Street 2:SUITE 103
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250-6073
Mailing Address - Country:US
Mailing Address - Phone:904-241-7865
Mailing Address - Fax:904-249-2352
Practice Address - Street 1:3316 3RD ST S
Practice Address - Street 2:SUITE 103
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-6073
Practice Address - Country:US
Practice Address - Phone:904-241-7865
Practice Address - Fax:904-249-2352
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN13682207W00000X
FLME118175207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology