Provider Demographics
NPI:1811407885
Name:DIAZ BAJUELO, CARLOS ALBERTO
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ALBERTO
Last Name:DIAZ BAJUELO
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 1:674 W 65TH DR
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6561
Mailing Address - Country:US
Mailing Address - Phone:305-256-1653
Mailing Address - Fax:305-256-1663
Practice Address - Street 1:674 W 65TH DR
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6561
Practice Address - Country:US
Practice Address - Phone:305-256-1653
Practice Address - Fax:305-256-1663
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician