Provider Demographics
NPI:1831321942
Name:HEREDIA VINTIMILLA, DIEGO JOSE (MD)
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:JOSE
Last Name:HEREDIA VINTIMILLA
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 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-1840
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:311 9TH ST N STE 304
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5887
Practice Address - Country:US
Practice Address - Phone:239-624-8250
Practice Address - Fax:239-624-8171
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME144293207R00000X
IN01074507A207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201289950Medicaid
INP01636990OtherRR MEDICARE
IN201289950Medicaid
INP01636990OtherRR MEDICARE