Provider Demographics
NPI:1881984862
Name:DIAZ, WALTER N (LMT)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:N
Last Name:DIAZ
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 SW 137TH AVE
Mailing Address - Street 2:110
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-6355
Mailing Address - Country:US
Mailing Address - Phone:786-313-3204
Mailing Address - Fax:786-313-3205
Practice Address - Street 1:2721 SW 137TH AVE
Practice Address - Street 2:110
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-6355
Practice Address - Country:US
Practice Address - Phone:786-313-3204
Practice Address - Fax:786-313-3205
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101324208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice