Provider Demographics
NPI:1932227428
Name:NANNETTE DIAZ DPM PA
Entity Type:Organization
Organization Name:NANNETTE DIAZ DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:813-960-1517
Mailing Address - Street 1:PO BOX 341306
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33694-1306
Mailing Address - Country:US
Mailing Address - Phone:813-960-1517
Mailing Address - Fax:813-962-3278
Practice Address - Street 1:3355 W BEARSS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618
Practice Address - Country:US
Practice Address - Phone:813-960-1517
Practice Address - Fax:813-962-3278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3049213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340531100Medicaid
FLV01956Medicare UPIN
FL5868840001Medicare NSC
FL340531100Medicaid