1316940463 NPI number — JORGE L. DIEZ MD

Table of content: JORGE L. DIEZ MD (NPI 1316940463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316940463 NPI number — JORGE L. DIEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIEZ
Provider First Name:
JORGE
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1316940463
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 JORDAN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WETHERSFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06109-1278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-263-0253
Provider Business Mailing Address Fax Number:
860-263-0262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
893 MAIN ST STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06108-2293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-247-2137
Provider Business Practice Location Address Fax Number:
860-728-0480
Provider Enumeration Date:
05/23/2005

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: 207RE0101X , with the licence number:  042533 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001425330 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".