Provider Demographics
NPI:1225355845
Name:DIAZ DE VIVAR, ANDREA (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:DIAZ DE VIVAR
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 421849
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77242-1849
Mailing Address - Country:US
Mailing Address - Phone:713-559-6929
Mailing Address - Fax:713-559-6928
Practice Address - Street 1:2525 W BELLFORT STREET
Practice Address - Street 2:STE 120
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-5024
Practice Address - Country:US
Practice Address - Phone:713-741-6677
Practice Address - Fax:713-748-5860
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2470207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX291402006Medicaid