Healthcare Provider Details

I. General information

NPI: 1891723599
Provider Name (Legal Business Name): JOSEFINO CALIBO DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 3RD ST
DULUTH MN
55805-1951
US

IV. Provider business mailing address

400 E 3RD ST
DULUTH MN
55805-1951
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-8364
  • Fax:
Mailing address:
  • Phone: 218-786-8364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number44952
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number44952
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: