Provider Demographics
NPI:1447771613
Name:DECARVALHO, DIEGO H (DO)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:H
Last Name:DECARVALHO
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:IRAHC
Mailing Address - Street 2:200 BRULE ST BLDG 871
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-6100
Mailing Address - Country:US
Mailing Address - Phone:512-703-0046
Mailing Address - Fax:502-626-9958
Practice Address - Street 1:200 BRULE ST
Practice Address - Street 2:IRAHC
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:512-703-0046
Practice Address - Fax:502-626-9958
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE2010207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program