Provider Demographics
NPI:1790851988
Name:DIAZ VIDAL, IVYA E (MD INTERNAL MEDICINE)
Entity type:Individual
Prefix:DR
First Name:IVYA
Middle Name:E
Last Name:DIAZ VIDAL
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Gender:F
Credentials:MD INTERNAL MEDICINE
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Mailing Address - Street 1:AVE LUIS MUNOZ MARIN 50
Mailing Address - Street 2:QUADRANGLE MEDICAL SUITE 106
Mailing Address - City:CAQUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726
Mailing Address - Country:US
Mailing Address - Phone:787-745-0022
Mailing Address - Fax:787-739-7199
Practice Address - Street 1:AVE LUIS MUNOZ MARIN 50
Practice Address - Street 2:QUADRANGLE MEDICAL SUITE 106
Practice Address - City:CAQUAS
Practice Address - State:PR
Practice Address - Zip Code:00726
Practice Address - Country:US
Practice Address - Phone:787-745-0022
Practice Address - Fax:787-739-7199
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2012-12-18
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Provider Licenses
StateLicense IDTaxonomies
PR10789207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0400592Medicaid
PR0087779Medicare ID - Type Unspecified
PR0400592Medicaid