Provider Demographics
NPI:1134109374
Name:DIAZ, IVETTE E (MD)
Entity type:Individual
Prefix:DR
First Name:IVETTE
Middle Name:E
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IVETTE
Other - Middle Name:E
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:304 FEDERAL RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-2418
Mailing Address - Country:US
Mailing Address - Phone:203-740-2593
Mailing Address - Fax:203-740-8250
Practice Address - Street 1:304 FEDERAL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-2418
Practice Address - Country:US
Practice Address - Phone:203-740-2593
Practice Address - Fax:203-740-8250
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-21
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035354207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine