Provider Demographics
NPI:1730755380
Name:DIAZ-SERRANO, LISSETTE
Entity type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:DIAZ-SERRANO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2053 W BIRCHWOOD AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-2173
Mailing Address - Country:US
Mailing Address - Phone:773-706-6197
Mailing Address - Fax:
Practice Address - Street 1:2053 W BIRCHWOOD AVE APT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-2173
Practice Address - Country:US
Practice Address - Phone:773-706-6197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR22344208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program