Provider Demographics
NPI:1114486636
Name:DIAZ BAEZ, ELSIE ANGELIC
Entity Type:Individual
Prefix:
First Name:ELSIE
Middle Name:ANGELIC
Last Name:DIAZ BAEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CC9 CALLE YUNQUESITO
Mailing Address - Street 2:URB MANSIONES DE CAROLINA
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987
Mailing Address - Country:US
Mailing Address - Phone:787-517-2363
Mailing Address - Fax:
Practice Address - Street 1:1185 AVE 65 INFANTERIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-3403
Practice Address - Country:US
Practice Address - Phone:787-999-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6606183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6303OtherIMMUNIZATION LICENCE