Provider Demographics
NPI:1467101980
Name:DIAZ-FERNANDEZ, JOSE GERARDO
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:GERARDO
Last Name:DIAZ-FERNANDEZ
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 1:2161 AVE MCLEARY APT 1F
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00913-4548
Mailing Address - Country:US
Mailing Address - Phone:787-597-8319
Mailing Address - Fax:
Practice Address - Street 1:10 CALLE CASIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-3200
Practice Address - Country:US
Practice Address - Phone:787-641-7582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR27201835P0018X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist