Provider Demographics
NPI:1154311264
Name:DIEGO, JOAQUIN NICOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOAQUIN
Middle Name:NICOLAS
Last Name:DIEGO
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 1:7190 SW 87 AVENUE
Mailing Address - Street 2:SUITE# 202
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-3259
Mailing Address - Country:US
Mailing Address - Phone:305-270-3075
Mailing Address - Fax:305-412-6338
Practice Address - Street 1:7190 SW 87TH AVE
Practice Address - Street 2:SUITE# 202
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-2507
Practice Address - Country:US
Practice Address - Phone:305-270-3075
Practice Address - Fax:305-412-6338
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56696207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004311OtherNHP
FL054326800Medicaid
E91773Medicare UPIN
12443Medicare ID - Type Unspecified