Provider Demographics
NPI:1770579245
Name:DIAZ ANDRES, ODELSA (MD)
Entity type:Individual
Prefix:DR
First Name:ODELSA
Middle Name:
Last Name:DIAZ ANDRES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-3833
Mailing Address - Country:US
Mailing Address - Phone:352-277-5305
Mailing Address - Fax:352-616-0926
Practice Address - Street 1:6279 N LECANTO HWY
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-2503
Practice Address - Country:US
Practice Address - Phone:352-522-0094
Practice Address - Fax:352-522-0098
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN757208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016457600Medicaid
FLV4VMNOtherBLUE CROSS BLUE SHIELD
FL016457600Medicaid
PR0023367Medicare PIN