Provider Demographics
NPI:1295222719
Name:DIAZ, JORGE MANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:MANUEL
Last Name:DIAZ
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 1:1084 W OAKLAND AVE APT 811
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2553
Mailing Address - Country:US
Mailing Address - Phone:423-747-4166
Mailing Address - Fax:
Practice Address - Street 1:400 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6035
Practice Address - Country:US
Practice Address - Phone:423-431-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X
TN65933207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program