Provider Demographics
NPI:1578978342
Name:DIAZ, JORGE ANDRES (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:ANDRES
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:90 FORT WADE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-5114
Mailing Address - Country:US
Mailing Address - Phone:904-466-8916
Mailing Address - Fax:904-302-6954
Practice Address - Street 1:90 FORT WADE RD STE 100
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32081-5114
Practice Address - Country:US
Practice Address - Phone:904-466-8916
Practice Address - Fax:904-302-6954
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1319302084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry