Provider Demographics
NPI:1346279809
Name:DIAZ, JORGE LUIS (DO)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 W 20TH AVE STE 401
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1811
Mailing Address - Country:US
Mailing Address - Phone:305-821-6112
Mailing Address - Fax:305-829-9050
Practice Address - Street 1:7100 W 20TH AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1897
Practice Address - Country:US
Practice Address - Phone:305-821-6112
Practice Address - Fax:305-821-9050
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7912207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019928600Medicaid
FLH12846Medicare UPIN
47057ZMedicare ID - Type Unspecified