Provider Demographics
NPI:1669400198
Name:DIEGO, JORGE M (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:M
Last Name:DIEGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2451 INTELLIPLEX DR
Mailing Address - Street 2:STE 260
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-8580
Mailing Address - Country:US
Mailing Address - Phone:305-243-4664
Mailing Address - Fax:305-243-9927
Practice Address - Street 1:2451 INTELLIPLEX DR STE 260
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8580
Practice Address - Country:US
Practice Address - Phone:317-398-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01077464A207RI0200X, 207RN0300X, 207RN0300X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2513323-00Medicaid
FL2513323-00Medicaid
FL32817Medicare UPIN