Provider Demographics
NPI:1316940463
Name:DIEZ, JORGE L (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:L
Last Name:DIEZ
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 1:30 JORDAN LN
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1278
Mailing Address - Country:US
Mailing Address - Phone:860-263-0253
Mailing Address - Fax:860-263-0262
Practice Address - Street 1:893 MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-2293
Practice Address - Country:US
Practice Address - Phone:860-247-2137
Practice Address - Fax:860-728-0480
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042533207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001425330Medicaid
CT001425330Medicaid
CT460000076Medicare ID - Type Unspecified