Provider Demographics
NPI:1710213038
Name:DIAZ BURGOS, ELMA (OD)
Entity Type:Individual
Prefix:
First Name:ELMA
Middle Name:
Last Name:DIAZ BURGOS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ELMA
Other - Middle Name:DIAZ
Other - Last Name:BURGOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646-0707
Mailing Address - Country:US
Mailing Address - Phone:787-879-6659
Mailing Address - Fax:787-879-6659
Practice Address - Street 1:348 CALLE B VICTOR ROJAS II
Practice Address - Street 2:SUITE 3
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612
Practice Address - Country:US
Practice Address - Phone:787-879-6659
Practice Address - Fax:787-879-6659
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR513152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist