Provider Demographics
NPI:1336106822
Name:DIAZ RUIZ, JAMIL TARECK (MD)
Entity Type:Individual
Prefix:MR
First Name:JAMIL
Middle Name:TARECK
Last Name:DIAZ RUIZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CALLE COLON STE 9
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-3167
Mailing Address - Country:US
Mailing Address - Phone:787-868-0045
Mailing Address - Fax:787-868-0045
Practice Address - Street 1:2 CALLE COLON STE 9
Practice Address - Street 2:
Practice Address - City:AGUADA
Practice Address - State:PR
Practice Address - Zip Code:00602-3167
Practice Address - Country:US
Practice Address - Phone:787-868-0045
Practice Address - Fax:787-868-0045
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12986208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0089930Medicare ID - Type Unspecified
PRG98589Medicare UPIN