Healthcare Provider Details

I. General information

NPI: 1932174794
Provider Name (Legal Business Name): DIEGO FALLON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5775 PEACHTREE DUNWOODY RD STE 425
ATLANTA GA
30342-1556
US

IV. Provider business mailing address

117 W BAY ST
WAUCHULA FL
33873-3135
US

V. Phone/Fax

Practice location:
  • Phone: 844-403-4325
  • Fax:
Mailing address:
  • Phone: 863-773-4700
  • Fax: 863-773-2916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME53500
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: