1194701573 NPI number — DIELY PICHARDO MD

Table of content: DIELY PICHARDO MD (NPI 1194701573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194701573 NPI number — DIELY PICHARDO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PICHARDO
Provider First Name:
DIELY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194701573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 534595
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30353-4595
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-255-2606
Provider Business Mailing Address Fax Number:
321-255-2807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1430 S PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-952-0898
Provider Business Practice Location Address Fax Number:
321-722-1342
Provider Enumeration Date:
12/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  ME91834 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 287612 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 3789162 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 03411 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 6000828001 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7653665 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 272209700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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