Provider Demographics
NPI:1871596098
Name:DIAZ-LACAYO, MARVIN (MD)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:DIAZ-LACAYO
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 1:21150 BISCAYNE BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1226
Mailing Address - Country:US
Mailing Address - Phone:305-932-4198
Mailing Address - Fax:305-932-9102
Practice Address - Street 1:21150 BISCAYNE BLVD
Practice Address - Street 2:STE 101
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1226
Practice Address - Country:US
Practice Address - Phone:305-932-4198
Practice Address - Fax:305-932-9102
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2007-12-28
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
FLME0022072174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL92110WMedicare PIN
FLK0393Medicare UPIN