Basic Information
| Provider Information | |||||||||
| NPI: | 1164726667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ BARCELO | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 S ORANGE AVE STE 940 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328013234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213326947 | ||||||||
| FaxNumber: | 4076589688 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 S SEMORAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328071457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073821376 | ||||||||
| FaxNumber: | 3212353232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2010 | ||||||||
| LastUpdateDate: | 06/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 18116 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN808 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | FD2561757 | 01 | FL | DEA | OTHER | ACN808 | 01 | FL | MEDICAL KICENSE | OTHER |