Basic Information
Provider Information | |||||||||
NPI: | 1699104265 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIAZ | ||||||||
FirstName: | ORLANDO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 616788 | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328616788 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4075336835 | ||||||||
FaxNumber: | 4077700661 | ||||||||
Practice Location | |||||||||
Address1: | 1050 CYPRESS PKWY | ||||||||
Address2: |   | ||||||||
City: | KISSIMMEE | ||||||||
State: | FL | ||||||||
PostalCode: | 347593328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4074831400 | ||||||||
FaxNumber: | 4074831405 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/05/2013 | ||||||||
LastUpdateDate: | 12/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 9298166 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 208D00000X | ACN1095 | FL | Y |   | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.