=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710914205
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HUGO DIEZ JR. PHYSICIAN/MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2006
-----------------------------------------------------
Last Update Date | 08/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11880 SW 40TH ST SUITE 218
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-3584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-251-3991
-----------------------------------------------------
Fax | 305-251-7982
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11880 SW 40TH ST SUITE 216
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-3584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-552-5792
-----------------------------------------------------
Fax | 305-552-6119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME0059913
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------