Provider Demographics
NPI:1558930552
Name:DIAZ ORTIZ, SAMUEL JOSHUA (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JOSHUA
Last Name:DIAZ ORTIZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SAMUEL
Other - Middle Name:JOSHUA
Other - Last Name:DIAZ ORTIZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:30 CALLE PRINCESA
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-3608
Mailing Address - Country:US
Mailing Address - Phone:787-388-9368
Mailing Address - Fax:
Practice Address - Street 1:CENTRO MEDICO DE PUERTO RICO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00935-0001
Practice Address - Country:US
Practice Address - Phone:787-777-3535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2023-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR22937208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty