Provider Demographics
NPI:1295748176
Name:DIAZ, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 S HARBOR CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-4681
Mailing Address - Country:US
Mailing Address - Phone:321-951-2639
Mailing Address - Fax:321-914-0938
Practice Address - Street 1:1513 S HARBOR CITY BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-951-2639
Practice Address - Fax:321-914-0938
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74679174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1033065OtherCAREPLUS HEALTH PLAN
EFFECTIVE 07/14/208OtherCOALITION AMERICA/NPPN
EFFECTIVE 08/07/2008OtherEVOLUTIONS
EFFECTIVE 10/01/2008OtherUNITEDHEALTHCARE
FL01226797OtherAMERIGROUP
FL44932OtherBCBS OF FLORIDA
458713OtherWELLCARE
EFFECTIVE 10/23/08OtherMULTIPLAN/PHCS
EFFECTIVE 11/01/2007OtherCOVENTRY
6684138OtherAETNA HMO
EFFECTIVE 01/01/2009OtherACCOUNTABLE/INTERPLAN HEALTH GROUP
EFFECTIVE 12/29/2008OtherHUMANA CHOICE CARE
2580722OtherBEECHSTREET NETWORK
7381303OtherAETNA PPO
EFFECTIVE 10/20/2008OtherCIGNA
EFFECTIVE 10/30/2008OtherTRICARE
EFFECTIVE 08/07/2008OtherEVOLUTIONS
EFFECTIVE 10/23/08OtherMULTIPLAN/PHCS