Provider Demographics
NPI:1669420782
Name:DIAZ, ROSENDO DIEGO (MD)
Entity type:Individual
Prefix:DR
First Name:ROSENDO
Middle Name:DIEGO
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:734 N 3RD ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5285
Mailing Address - Country:US
Mailing Address - Phone:352-365-2583
Mailing Address - Fax:352-728-6749
Practice Address - Street 1:801 E DIXIE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7601
Practice Address - Country:US
Practice Address - Phone:352-365-2583
Practice Address - Fax:352-728-6749
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME400282085R0202X, 2085N0700X
FL40028207RM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207RM1200XAllopathic & Osteopathic PhysiciansInternal MedicineMagnetic Resonance Imaging (MRI)
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300133479OtherRR MEDICARE RACF
FL300133480OtherRR MEDICARE LMIV
FL046908400Medicaid
FL96308WMedicare PIN
FL300133479OtherRR MEDICARE RACF
FLB78517Medicare UPIN