Provider Demographics
NPI:1780627588
Name:DIAZ VELAZQUEZ, MAGDA IRIS (OD)
Entity type:Individual
Prefix:DR
First Name:MAGDA
Middle Name:IRIS
Last Name:DIAZ VELAZQUEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00785-0629
Mailing Address - Country:US
Mailing Address - Phone:787-605-1943
Mailing Address - Fax:
Practice Address - Street 1:AVE LOS VETERANOS CARR. #3 KM 134.7
Practice Address - Street 2:WALMART, PLAZA GUAYAMA
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784
Practice Address - Country:US
Practice Address - Phone:787-605-1943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR618152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist