Provider Demographics
NPI:1811754880
Name:DIAZ VARGAS, JESUS
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:DIAZ VARGAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-3138
Mailing Address - Country:US
Mailing Address - Phone:786-782-5653
Mailing Address - Fax:
Practice Address - Street 1:202 E 17TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-3138
Practice Address - Country:US
Practice Address - Phone:786-782-5653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCM.0106500-P171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator