Provider Demographics
NPI:1700205523
Name:PUELLO DIAZ, PABLO EMMANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:PABLO
Middle Name:EMMANUEL
Last Name:PUELLO DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:920 37TH PL STE 105
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6595
Mailing Address - Country:US
Mailing Address - Phone:772-978-5811
Mailing Address - Fax:772-978-5815
Practice Address - Street 1:920 37TH PL STE 105
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6595
Practice Address - Country:US
Practice Address - Phone:772-978-5811
Practice Address - Fax:772-978-5815
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME143430207RN0300X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106057600Medicaid