Healthcare Provider Details

I. General information

NPI: 1497867121
Provider Name (Legal Business Name): CARMENCITA DIAZ-SY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21544 24TH AVE
BAYSIDE NY
11360-2220
US

IV. Provider business mailing address

21544 24TH AVE
BAYSIDE NY
11360-2220
US

V. Phone/Fax

Practice location:
  • Phone: 718-428-7641
  • Fax: 718-225-8671
Mailing address:
  • Phone: 718-428-7641
  • Fax: 718-225-8671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number145572
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: