Provider Demographics
NPI:1922522010
Name:DIAZ, VICTOR IVAN JR
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:IVAN
Last Name:DIAZ
Suffix:JR
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 1:700 CALLE DR PAVIA FERNANDEZ STE 301
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00909-2757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 CALLE DR PAVIA FERNANDEZ
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-2758
Practice Address - Country:US
Practice Address - Phone:787-496-0818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR31105102405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional