Provider Demographics
NPI:1396191813
Name:DIAZ, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:J-9 CALLE FLAMBOYAN
Mailing Address - Street 2:URB BOSQUE LLANO
Mailing Address - City:SAN LORENZO
Mailing Address - State:PR
Mailing Address - Zip Code:00754
Mailing Address - Country:US
Mailing Address - Phone:787-203-9985
Mailing Address - Fax:
Practice Address - Street 1:I10 CALLE 6
Practice Address - Street 2:URB TAMARINDO 1
Practice Address - City:SAN LORENZO
Practice Address - State:PR
Practice Address - Zip Code:00754
Practice Address - Country:US
Practice Address - Phone:787-340-5103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR71810163WP2201X, 261QH0100X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health