Provider Demographics
NPI:1649479536
Name:JIMMY DIAZ MD PC
Entity type:Organization
Organization Name:JIMMY DIAZ MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-729-6606
Mailing Address - Street 1:130 N GROSS RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548
Mailing Address - Country:US
Mailing Address - Phone:912-729-6606
Mailing Address - Fax:912-729-1214
Practice Address - Street 1:130 N GROSS RD
Practice Address - Street 2:SUITE 202
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548
Practice Address - Country:US
Practice Address - Phone:912-729-6606
Practice Address - Fax:912-729-1214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363AM0700X
GA26097207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000320581EMedicaid
D 39743Medicare UPIN
GAD39743Medicare UPIN
GAGRP7111Medicare PIN