Provider Demographics
NPI:1952924201
Name:DIAZ GARCED, JORGE HUMBERTO
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:HUMBERTO
Last Name:DIAZ GARCED
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:VILLAS DE BUENAVENTURA
Mailing Address - Street 2:422 C/ LUQUILLO
Mailing Address - City:YABUCOA
Mailing Address - State:PR
Mailing Address - Zip Code:00767
Mailing Address - Country:US
Mailing Address - Phone:939-277-4599
Mailing Address - Fax:
Practice Address - Street 1:69 CALLE JESUS T PINERO
Practice Address - Street 2:
Practice Address - City:LAS PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00771-3004
Practice Address - Country:US
Practice Address - Phone:787-733-2263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR478PA363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant