Provider Demographics
NPI:1720513393
Name:DIAZ VAZQUEZ, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:DIAZ VAZQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26205 SW 144TH AVE APT 311
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5665
Mailing Address - Country:US
Mailing Address - Phone:602-554-4510
Mailing Address - Fax:
Practice Address - Street 1:26205 SW 144TH AVE STE 109
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-5657
Practice Address - Country:US
Practice Address - Phone:786-752-7029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020786300Medicaid