Basic Information
Provider Information
NPI: 1649479536
EntityType: 2
ReplacementNPI:  
OrganizationName: JIMMY DIAZ MD PC
LastName:  
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Mailing Information
Address1: 130 N GROSS RD
Address2: SUITE 202
City: KINGSLAND
State: GA
PostalCode: 31548
CountryCode: US
TelephoneNumber: 9127296606
FaxNumber: 9127291214
Practice Location
Address1: 130 N GROSS RD
Address2: SUITE 202
City: KINGSLAND
State: GA
PostalCode: 31548
CountryCode: US
TelephoneNumber: 9127296606
FaxNumber: 9127291214
Other Information
ProviderEnumerationDate: 07/12/2007
LastUpdateDate: 08/01/2008
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: DIAZ
AuthorizedOfficialFirstName: JIMMY
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 9127296606
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363AM0700X GAN193200000X MULTI-SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
207R00000X26097GAY193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 

ID Information
IDTypeStateIssuerDescription
000320581E05GA MEDICAID


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