Provider Demographics
NPI:1396853891
Name:DIAZ, JIMMY (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:
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 1:218 QUARTERMAN ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-3547
Mailing Address - Country:US
Mailing Address - Phone:912-729-6606
Mailing Address - Fax:912-729-4307
Practice Address - Street 1:214 PROFESSIONAL CIR STE A
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3783
Practice Address - Country:US
Practice Address - Phone:912-729-6606
Practice Address - Fax:912-729-4307
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA26097207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000320581EMedicaid
11SCDXNMedicare PIN
GA11SCDXNMedicare PIN
GA000320581EMedicaid