Provider Demographics
NPI:1669760021
Name:ALCIVAR FRANCO, DIEGO FERNANDO (MD)
Entity type:Individual
Prefix:DR
First Name:DIEGO
Middle Name:FERNANDO
Last Name:ALCIVAR FRANCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5800
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-268-5800
Practice Address - Fax:601-261-3530
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR2689207R00000X
MS26634207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03222340Medicaid
KYFA3711581OtherDEA NUMBER
KYR2689OtherKY LICENSE