Provider Demographics
NPI:1518090893
Name:ORTIZ, NYDIAZ ROSA (5776)
Entity Type:Individual
Prefix:
First Name:NYDIAZ
Middle Name:ROSA
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:5776
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CALLE SAN MANUEL
Mailing Address - Street 2:
Mailing Address - City:COROZAL
Mailing Address - State:PR
Mailing Address - Zip Code:00783
Mailing Address - Country:US
Mailing Address - Phone:787-366-6139
Mailing Address - Fax:
Practice Address - Street 1:1 SAN MANUEL
Practice Address - Street 2:
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783
Practice Address - Country:US
Practice Address - Phone:787-859-2729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5776183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician