MEDICARE: DR. LISETTE Y. PEREZ 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	207Y00000X	Otolaryngology Physician	11652	PR

General Provider Information

NPI Number	:	1285637504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISETTE Y. PEREZ DIAZ M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1036
Second Line	:
City	:	GUAYNABO
State	:	PR
Zip	:	00970-1036
Country	:	US
Telephone Number	:	787-706-4334
Fax Number	:	787-749-0993

Provider Business Practice Location Address
First Line	:	1510 AVE FD ROOSEVELT
Second Line	:	MEZZANINE SUITE B
City	:	GUAYNABO
State	:	PR
Zip	:	00968-2602
Country	:	US
Telephone Number	:	787-706-4334
Fax Number	:	787-749-0993

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

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	06/23/2015

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