Provider Demographics
NPI:1033286034
Name:DIVERSIFIED MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:DIVERSIFIED MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DELGADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-662-8559
Mailing Address - Street 1:18619 SW 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-6728
Mailing Address - Country:US
Mailing Address - Phone:305-662-8559
Mailing Address - Fax:305-667-6280
Practice Address - Street 1:18619 SW 107TH AVE
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-6728
Practice Address - Country:US
Practice Address - Phone:305-662-8559
Practice Address - Fax:305-667-6280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL847332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025107100Medicaid
FL0397540001Medicare NSC