Provider Demographics
NPI:1457397507
Name:DIAZ, ERNESTO (MD)
Entity Type:Individual
Prefix:
First Name:ERNESTO
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 1:2121 SW 3RD AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33129-1470
Mailing Address - Country:US
Mailing Address - Phone:305-649-6077
Mailing Address - Fax:305-649-6071
Practice Address - Street 1:3091 CORAL WAY
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33145-3212
Practice Address - Country:US
Practice Address - Phone:305-649-6077
Practice Address - Fax:305-649-6071
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 67442207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376953400Medicaid
FL26387Medicare ID - Type UnspecifiedMEDICARE