Basic Information
| Provider Information | |||||||||
| NPI: | 1548415086 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394241479 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2780 CLEVELAND AVE | ||||||||
| Address2: | # 702 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393433474 | ||||||||
| FaxNumber: | 2393432968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2008 | ||||||||
| LastUpdateDate: | 08/02/2018 | ||||||||
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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 | 2086S0102X | ME92159 | FL | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | ME92159 | FL | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000771800 | 05 | FL | MEDICAID |