Provider Demographics
NPI:1053416388
Name:CORDOBA, DIEGO R (MD)
Entity type:Individual
Prefix:DR
First Name:DIEGO
Middle Name:R
Last Name:CORDOBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 MEDICAL ARTS BLDG
Mailing Address - Street 2:SUITE 140
Mailing Address - City:KITTANNING
Mailing Address - State:PA
Mailing Address - Zip Code:16201-7135
Mailing Address - Country:US
Mailing Address - Phone:724-548-4701
Mailing Address - Fax:724-548-2003
Practice Address - Street 1:100 MEDICAL ARTS BLDG
Practice Address - Street 2:SUITE 140
Practice Address - City:KITTANNING
Practice Address - State:PA
Practice Address - Zip Code:16201-7135
Practice Address - Country:US
Practice Address - Phone:724-548-4701
Practice Address - Fax:724-548-2003
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PA035116-L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010179980003Medicaid
PAB36699Medicare UPIN
PA0010179980003Medicaid