Provider Demographics
NPI:1083177851
Name:DIAZ VERA, JESUS
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:DIAZ VERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JESUS
Other - Middle Name:
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10460 ROOSEVELT BLVD N # 169
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-3821
Mailing Address - Country:US
Mailing Address - Phone:727-420-6374
Mailing Address - Fax:
Practice Address - Street 1:1258 W BAY DR STE D
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2277
Practice Address - Country:US
Practice Address - Phone:727-420-6374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME168436207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease