Provider Demographics
NPI:1285637504
Name:PEREZ DIAZ, LISETTE Y (MD)
Entity Type:Individual
Prefix:DR
First Name:LISETTE
Middle Name:Y
Last Name:PEREZ DIAZ
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 1036
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970-1036
Mailing Address - Country:US
Mailing Address - Phone:787-706-4334
Mailing Address - Fax:787-749-0993
Practice Address - Street 1:1510 AVE FD ROOSEVELT
Practice Address - Street 2:MEZZANINE SUITE B
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00968-2602
Practice Address - Country:US
Practice Address - Phone:787-706-4334
Practice Address - Fax:787-749-0993
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11652207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG07101Medicare UPIN
PR87601Medicare ID - Type Unspecified