Basic Information
| Provider Information | |||||||||
| NPI: | 1295222719 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | MANUEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1084 W OAKLAND AVE APT 811 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237474166 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 N STATE OF FRANKLIN RD | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234316111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2018 | ||||||||
| LastUpdateDate: | 08/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | TN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 65933 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.