Provider Demographics
NPI:1558468389
Name:DIEGO R. CORDOBA, M.D. LTD
Entity Type:Organization
Organization Name:DIEGO R. CORDOBA, M.D. LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIEGO
Authorized Official - Middle Name:R
Authorized Official - Last Name:CORDOBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-548-4701
Mailing Address - Street 1:100 MEDICAL ARTS BLDG
Mailing Address - Street 2:SUITE 140
Mailing Address - City:KITTANNING
Mailing Address - State:PA
Mailing Address - Zip Code:16201-7135
Mailing Address - Country:US
Mailing Address - Phone:724-548-4701
Mailing Address - Fax:724-548-2003
Practice Address - Street 1:100 MEDICAL ARTS BLDG
Practice Address - Street 2:SUITE 140
Practice Address - City:KITTANNING
Practice Address - State:PA
Practice Address - Zip Code:16201-7135
Practice Address - Country:US
Practice Address - Phone:724-548-4701
Practice Address - Fax:724-548-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035116L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010179980003Medicaid
PA0010179980003Medicaid
PAB36699Medicare UPIN