Provider Demographics
NPI:1699157180
Name:DIAZ, JORGE B (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:B
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8011 N HIMES AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2700
Mailing Address - Country:US
Mailing Address - Phone:813-488-1414
Mailing Address - Fax:813-488-1413
Practice Address - Street 1:8011 N HIMES AVE STE 4
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2700
Practice Address - Country:US
Practice Address - Phone:813-488-1414
Practice Address - Fax:813-488-1413
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN671208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLACN671OtherMEDICAL LICENSE