Provider Demographics
NPI:1386784684
Name:DE DIEGO, JORGE ALBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:ALBERTO
Last Name:DE DIEGO
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 1:6446 NW 113TH CT
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-3618
Mailing Address - Country:US
Mailing Address - Phone:305-477-7111
Mailing Address - Fax:305-640-0277
Practice Address - Street 1:10820 NW 58TH ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2854
Practice Address - Country:US
Practice Address - Phone:305-477-7111
Practice Address - Fax:305-594-3126
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48450208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043536800Medicaid