Provider Demographics
NPI:1679639785
Name:ROMAN-DIAZ, MIGUEL A (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
Last Name:ROMAN-DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MIGUEL
Other - Middle Name:A
Other - Last Name:ROMAN-DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:909 CALLE ALAMEDA
Mailing Address - Street 2:VILLA GRANADA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00923-2719
Mailing Address - Country:US
Mailing Address - Phone:787-688-2779
Mailing Address - Fax:787-625-3227
Practice Address - Street 1:909 CALLE ALAMEDA
Practice Address - Street 2:VILLA GRANADA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00923-2719
Practice Address - Country:US
Practice Address - Phone:787-755-7171
Practice Address - Fax:787-625-3227
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9028207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR88907Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER