Basic Information
Provider Information
NPI: 1003016775
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DIAZ
FirstName: ANTONIO
MiddleName: LUIS
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 844 ESTANCIAS DEL BOULEVARD
Address2: BOX 143
City: SAN JUAN
State: PR
PostalCode: 009260000
CountryCode: US
TelephoneNumber: 7872409909
FaxNumber:  
Practice Location
Address1: 7000 CARR 844 # 844
Address2: BOX 143
City: SAN JUAN
State: PR
PostalCode: 009269570
CountryCode: US
TelephoneNumber: 7876086304
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/20/2007
LastUpdateDate: 05/03/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X26095PRY Allopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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