Provider Demographics
NPI:1205838513
Name:DIEZ-MORALES, LUIS (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:DIEZ-MORALES
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 1:1000 ASYLUM AVE
Mailing Address - Street 2:STE 2109A
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1719
Mailing Address - Country:US
Mailing Address - Phone:860-714-6581
Mailing Address - Fax:860-714-8311
Practice Address - Street 1:1000 ASYLUM AVE
Practice Address - Street 2:STE 1004
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1770
Practice Address - Country:US
Practice Address - Phone:860-714-4532
Practice Address - Fax:860-714-8275
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025560207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001255604Medicaid
CTE37704Medicare UPIN
CT001255604Medicaid