Provider Demographics
NPI:1447415245
Name:DIAZ, JORGE H
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:H
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:PMB 600 DE DIEGO #89
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927
Mailing Address - Country:US
Mailing Address - Phone:787-751-4310
Mailing Address - Fax:787-765-1064
Practice Address - Street 1:238 CALLE LAS MARIAS
Practice Address - Street 2:URB HYDE PARK
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00927-4222
Practice Address - Country:US
Practice Address - Phone:787-751-4310
Practice Address - Fax:787-765-1064
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR534291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR38117Medicare PIN