Provider Demographics
NPI:1497122022
Name:DIAZ, JESUS EDGARDO
Entity Type:Individual
Prefix:MR
First Name:JESUS
Middle Name:EDGARDO
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 45TH ST
Mailing Address - Street 2:ROOM L-200
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2361
Mailing Address - Country:US
Mailing Address - Phone:561-514-5360
Mailing Address - Fax:561-514-5550
Practice Address - Street 1:1150 45TH ST
Practice Address - Street 2:ROOM L-200
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2361
Practice Address - Country:US
Practice Address - Phone:561-514-5360
Practice Address - Fax:561-514-5550
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSU28604246QL0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030448400Medicaid
FLL9020Medicare PIN