Provider Demographics
NPI:1598396129
Name:DIAZ, DIEGO JOSE (BS)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:JOSE
Last Name:DIAZ
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:H4 CALLE ANDALUCIA
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983-1506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:H4 CALLE ANDALUCIA
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00983-1506
Practice Address - Country:US
Practice Address - Phone:939-475-4175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-02
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR36719207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program