Provider Demographics
NPI:1619943396
Name:DIAZ, EDUARDO
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:
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:BONEVILLE TERRACE C4 E-8
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:787-263-0965
Mailing Address - Fax:787-263-0965
Practice Address - Street 1:MUNOZ RIVERA 114 SUR
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736
Practice Address - Country:US
Practice Address - Phone:787-263-0965
Practice Address - Fax:787-263-0965
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8942208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0080371Medicare ID - Type Unspecified
PRE43436Medicare UPIN