Provider Demographics
NPI:1841328184
Name:DIAZ, IVAN (PT)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10220 EASTERN LAKE AVE
Mailing Address - Street 2:APT 204
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-5849
Mailing Address - Country:US
Mailing Address - Phone:407-394-8172
Mailing Address - Fax:
Practice Address - Street 1:1890 W COUNTY ROAD 419
Practice Address - Street 2:SUITE 1000
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-4402
Practice Address - Country:US
Practice Address - Phone:407-542-0899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21431225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist