Provider Demographics
NPI:1205878261
Name:DIAZ, JORGE G (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:G
Last Name:DIAZ
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N FLAMINGO RD STE 104
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1007
Mailing Address - Country:US
Mailing Address - Phone:954-284-0801
Mailing Address - Fax:954-983-1152
Practice Address - Street 1:601 N FLAMINGO RD STE 104
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1007
Practice Address - Country:US
Practice Address - Phone:954-284-0801
Practice Address - Fax:954-983-1152
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0061870207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL203739414Medicaid
FLF50766Medicare UPIN
FL18430Medicare ID - Type Unspecified