Provider Demographics
NPI:1144474560
Name:DIAZ, MERCEDES MAYRA (DO)
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:MAYRA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DO
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 374
Mailing Address - Street 2:
Mailing Address - City:MERCEDITA
Mailing Address - State:PR
Mailing Address - Zip Code:00715-0374
Mailing Address - Country:US
Mailing Address - Phone:787-848-4614
Mailing Address - Fax:787-848-4614
Practice Address - Street 1:396 ZONA IND REPARADA 2
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-2347
Practice Address - Country:US
Practice Address - Phone:787-848-4614
Practice Address - Fax:787-848-4614
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR511156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician