Provider Demographics
NPI:1760020051
Name:DIAZ, JOSE G (BSHE)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:G
Last Name:DIAZ
Suffix:
Gender:M
Credentials:BSHE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 CARR 876 APT 135
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-7520
Mailing Address - Country:US
Mailing Address - Phone:787-637-2970
Mailing Address - Fax:
Practice Address - Street 1:20 CALLE SANTA CRUZ
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-6906
Practice Address - Country:US
Practice Address - Phone:787-778-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR267174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator