Basic Information
| Provider Information | |||||||||
| NPI: | 1194701573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PICHARDO | ||||||||
| FirstName: | DIELY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 534595 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303534595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212552606 | ||||||||
| FaxNumber: | 3212552807 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 S PINE ST | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219520898 | ||||||||
| FaxNumber: | 3217221342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 01/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | ME91834 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 287612 | 01 | FL | WELLCARE | OTHER | 3789162 | 01 | FL | AETNA | OTHER | 03411 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 6000828001 | 01 | FL | CIGNA | OTHER | 7653665 | 01 | FL | AETNA | OTHER | 272209700 | 05 | FL | MEDICAID |