Basic Information
| Provider Information | |||||||||
| NPI: | 1396853891 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | JIMMY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 218 QUARTERMAN ST | ||||||||
| Address2: | |||||||||
| City: | WAYCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315013547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127296606 | ||||||||
| FaxNumber: | 9127294307 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 PROFESSIONAL CIR STE A | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315583783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127296606 | ||||||||
| FaxNumber: | 9127294307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2006 | ||||||||
| LastUpdateDate: | 10/24/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 26097 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000320581E | 05 | GA | MEDICAID |