Healthcare Provider Details

I. General information

NPI: 1134213366
Provider Name (Legal Business Name): DIEGO FALLON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W BAY ST
WAUCHULA FL
33873-3135
US

IV. Provider business mailing address

117 W BAY ST
WAUCHULA FL
33873-3135
US

V. Phone/Fax

Practice location:
  • Phone: 863-773-4700
  • Fax: 863-773-2916
Mailing address:
  • Phone: 863-773-4700
  • Fax: 863-773-2916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: DIEGO FALLON
Title or Position: OWNER
Credential: MD
Phone: 863-773-4700