Provider Demographics
NPI:1669909321
Name:DIAZ, CARLOS A
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CARLOS
Other - Middle Name:A
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:8930 SW 68TH CT APT 8
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-1517
Mailing Address - Country:US
Mailing Address - Phone:305-200-6733
Mailing Address - Fax:
Practice Address - Street 1:1900 BRICKELL AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33129-1719
Practice Address - Country:US
Practice Address - Phone:305-200-6733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA24712405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional