Provider Demographics
NPI:1457479941
Name:RIVERA-DIAZ, JORGE (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:RIVERA-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 1:15720 SW 45TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-3811
Mailing Address - Country:US
Mailing Address - Phone:305-221-7457
Mailing Address - Fax:305-480-8056
Practice Address - Street 1:681 EAST 9TH STREET
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010
Practice Address - Country:US
Practice Address - Phone:305-805-8550
Practice Address - Fax:305-805-8549
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
26555Medicare ID - Type Unspecified
F99641Medicare UPIN