Provider Demographics
NPI:1689659062
Name:DIAZ, MANUEL JESUS (MD)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:JESUS
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 SW 57TH AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5551
Mailing Address - Country:US
Mailing Address - Phone:305-476-7771
Mailing Address - Fax:305-442-0121
Practice Address - Street 1:7800 SW 57TH AVE STE 106
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-5551
Practice Address - Country:US
Practice Address - Phone:305-476-7771
Practice Address - Fax:305-442-0121
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88049174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268539600Medicaid
FLH90926Medicare UPIN