Healthcare Provider Details

I. General information

NPI: 1629271408
Provider Name (Legal Business Name): DIEGO MARTIN CAIVANO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 12/01/2021
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

393 E WALNUT ST PHR GROUP PROVIDER ENROLLMENT UNIT 3RD FL
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 904-346-0113
  • Fax:
Mailing address:
  • Phone: 877-608-0044
  • Fax: 877-514-0903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number234090-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101241979
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberC54160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: