Provider Demographics
NPI:1073553848
Name:DIAZ-FUENTES, GILDA (MD)
Entity Type:Individual
Prefix:DR
First Name:GILDA
Middle Name:
Last Name:DIAZ-FUENTES
Suffix:
Gender:F
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:PO BOX 1786
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-1786
Mailing Address - Country:US
Mailing Address - Phone:718-901-8154
Mailing Address - Fax:718-901-8151
Practice Address - Street 1:1770 GRAND CONCOURSE
Practice Address - Street 2:2G
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-5524
Practice Address - Country:US
Practice Address - Phone:718-518-5581
Practice Address - Fax:718-299-1877
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY201175207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01613950Medicaid
NY01613950Medicaid
NY45J391Medicare ID - Type Unspecified