Provider Demographics
NPI:1295111672
Name:DIAZ DE ORTIZ, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DIAZ DE ORTIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10125 W COLONIAL DR STE 205
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4200
Mailing Address - Country:US
Mailing Address - Phone:407-578-1241
Mailing Address - Fax:407-578-1242
Practice Address - Street 1:10125 W COLONIAL DR STE 205
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4200
Practice Address - Country:US
Practice Address - Phone:407-578-1241
Practice Address - Fax:407-578-1242
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-07
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME147279208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108126000Medicaid