Provider Demographics
NPI:1083287866
Name:JORGE O. DIAZ, MD PA
Entity Type:Organization
Organization Name:JORGE O. DIAZ, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:O
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-444-4848
Mailing Address - Street 1:5224 SR 46 # 376
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-9230
Mailing Address - Country:US
Mailing Address - Phone:407-444-4848
Mailing Address - Fax:407-444-4870
Practice Address - Street 1:1825 SALK AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4311
Practice Address - Country:US
Practice Address - Phone:407-444-4848
Practice Address - Fax:407-444-4870
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JORGE O. DIAZ, MD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-20
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015249701Medicaid