Provider Demographics
NPI:1871574186
Name:DIAZ, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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:PO BOX 102222
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:1201 5TH AVE N STE 505
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1455
Practice Address - Country:US
Practice Address - Phone:727-821-0017
Practice Address - Fax:727-821-7473
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84878207RH0000X, 207RX0202X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272291700Medicaid
FLP00369100OtherRR MEDICARE
FL272291700Medicaid
FL1168350001Medicare NSC
FL64110YMedicare PIN
FL64110ZMedicare PIN
I32242Medicare UPIN