Provider Demographics
NPI:1144491945
Name:DIAZ, CARMEN
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 ST. UU-1
Mailing Address - Street 2:PMB 117 URB. SANTA JUANITA
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956
Mailing Address - Country:US
Mailing Address - Phone:787-288-0657
Mailing Address - Fax:
Practice Address - Street 1:518 CALLE DRESDE
Practice Address - Street 2:PUERTO NUEVO
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00920-3731
Practice Address - Country:US
Practice Address - Phone:787-706-0209
Practice Address - Fax:787-774-5991
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6148060001Medicare NSC