Provider Demographics
NPI:1821321191
Name:BOLO DIAZ, MIREYA M (MD)
Entity Type:Individual
Prefix:
First Name:MIREYA
Middle Name:M
Last Name:BOLO DIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1838
Mailing Address - Street 2:
Mailing Address - City:COROZAL
Mailing Address - State:PR
Mailing Address - Zip Code:00783-1838
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:787-693-2010
Practice Address - Street 1:CARR. 891 KM. 15.2 BO. PUEBLO
Practice Address - Street 2:
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783
Practice Address - Country:US
Practice Address - Phone:787-944-3337
Practice Address - Fax:787-693-2010
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-17
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18363208000000X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics