Healthcare Provider Details

I. General information

NPI: 1396373569
Provider Name (Legal Business Name): JESUS ERNESTO DIAZ REGALADO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 CAPE CORAL PKWY E
CAPE CORAL FL
33904-8545
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-541-4420
  • Fax: 239-468-7908
Mailing address:
  • Phone: 395-414-4202
  • Fax: 239-468-7908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME163782
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: