Healthcare Provider Details

I. General information

NPI: 1427729193
Provider Name (Legal Business Name): MARIA DIAZ MENJIVAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 09/23/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 N. BROADWAY SUITE 2B
YONKERS NY
10701
US

IV. Provider business mailing address

24 LAYTON AVE PH
STATEN ISLAND NY
10301-1429
US

V. Phone/Fax

Practice location:
  • Phone: 718-866-4569
  • Fax:
Mailing address:
  • Phone: 347-968-9070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: