Provider Demographics
NPI:1164473633
Name:JARAMILLO, DIEGO (MD)
Entity type:Individual
Prefix:DR
First Name:DIEGO
Middle Name:
Last Name:JARAMILLO
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 1:10 W 66TH ST APT 33D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-6232
Mailing Address - Country:US
Mailing Address - Phone:305-965-2962
Mailing Address - Fax:
Practice Address - Street 1:630 W 168TH ST # MC28
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3725
Practice Address - Country:US
Practice Address - Phone:305-965-2962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2947552085P0229X
FLME 1301372085P0229X
PAMD4246732085P0229X, 2085R0202X
CAC1321042085P0229X, 2085R0202X
NY2947552085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011534370001Medicaid
PA1011534370001Medicaid
PA1011534370001Medicaid
PA082406Medicare ID - Type Unspecified