Provider Demographics
NPI:1194379750
Name:DIAZ OLMEDA, LISSETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISSETTE
Middle Name:
Last Name:DIAZ OLMEDA
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 1:306 CALLE CARIBE URB. ARROYO DEL MAR
Mailing Address - Street 2:
Mailing Address - City:ARROYO
Mailing Address - State:PR
Mailing Address - Zip Code:00714-3057
Mailing Address - Country:US
Mailing Address - Phone:787-362-8981
Mailing Address - Fax:
Practice Address - Street 1:306 CALLE CARIBE URB. ARROYO DEL MAR
Practice Address - Street 2:
Practice Address - City:ARROYO
Practice Address - State:PR
Practice Address - Zip Code:00714-3057
Practice Address - Country:US
Practice Address - Phone:787-362-8981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21506208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice