Provider Demographics
NPI:1730640103
Name:DIAZ SISO, JESUS RODRIGO (MD)
Entity Type:Individual
Prefix:DR
First Name:JESUS
Middle Name:RODRIGO
Last Name:DIAZ SISO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J. RODRIGO
Other - Middle Name:
Other - Last Name:DIAZ SISO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4802 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program