Provider Demographics
NPI:1801801600
Name:DR CARMEN DIAZ PA
Entity type:Organization
Organization Name:DR CARMEN DIAZ PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:786-514-8812
Mailing Address - Street 1:5563 SW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-1057
Mailing Address - Country:US
Mailing Address - Phone:786-514-8812
Mailing Address - Fax:
Practice Address - Street 1:2100 PONCE DE LEON BLVD STE 1015
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-5240
Practice Address - Country:US
Practice Address - Phone:786-514-8812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4145103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID#
FLQ0426Medicare UPIN