Provider Demographics
NPI:1760514194
Name:DIAZ CRUZ, MILDRED S (MD)
Entity Type:Individual
Prefix:MRS
First Name:MILDRED
Middle Name:S
Last Name:DIAZ CRUZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MILDRED
Other - Middle Name:S
Other - Last Name:DIAZ CRUZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 7545
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-7545
Mailing Address - Country:US
Mailing Address - Phone:787-536-7715
Mailing Address - Fax:
Practice Address - Street 1:10 CALLE DANIEL FLORES
Practice Address - Street 2:
Practice Address - City:JUNCOS
Practice Address - State:PR
Practice Address - Zip Code:00777-3411
Practice Address - Country:US
Practice Address - Phone:787-734-1780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9857208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0082281Medicare ID - Type UnspecifiedGENERALISTA