Provider Demographics
NPI:1821069238
Name:DIAZ DEVILLEGAS, GRISELL CARIDAD (MD)
Entity Type:Individual
Prefix:MRS
First Name:GRISELL
Middle Name:CARIDAD
Last Name:DIAZ DEVILLEGAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2135 S CONGRESS AVE
Mailing Address - Street 2:BLDG 2 SUITE A B
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406
Mailing Address - Country:US
Mailing Address - Phone:561-641-0811
Mailing Address - Fax:561-641-0813
Practice Address - Street 1:2135 S CONGRESS AVE
Practice Address - Street 2:BLDG 2 SUITE A B
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406
Practice Address - Country:US
Practice Address - Phone:561-641-0811
Practice Address - Fax:561-641-0813
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0068858208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251597100Medicaid
FL251597100Medicaid