MEDICARE: DR. LILLIAN IBETH DIAZ M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	191927	NY

General Provider Information

NPI Number	:	1093874034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LILLIAN IBETH DIAZ M.D.

Provider Business Mailing Address
First Line	:	235 PORT RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-1701
Country	:	US
Telephone Number	:	718-876-1762
Fax Number	:	718-876-3459

Provider Business Practice Location Address
First Line	:	235 PORT RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-1701
Country	:	US
Telephone Number	:	718-876-1762
Fax Number	:	718-876-3459

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	07/08/2007

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