Provider Demographics
NPI:1053357707
Name:CORDERO, DIANA M (MD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:M
Last Name:CORDERO
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 1:3720 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3814
Mailing Address - Country:US
Mailing Address - Phone:904-475-2039
Mailing Address - Fax:904-330-0668
Practice Address - Street 1:3720 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-3814
Practice Address - Country:US
Practice Address - Phone:904-475-2039
Practice Address - Fax:904-330-0668
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0057227207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00906112OtherMEDICARE RAILROAD
FL004693201Medicaid
FLAP583TMedicare PIN