Healthcare Provider Details

I. General information

NPI: 1629322789
Provider Name (Legal Business Name): ROSA DIAZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2012
Last Update Date: 09/09/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KILOMETER 11.7, PR-2 SUITE 611
BAYAMON PR
00959
US

IV. Provider business mailing address

PO BOX 262152
SAN JUAN PR
00926-2652
US

V. Phone/Fax

Practice location:
  • Phone: 787-502-9459
  • Fax:
Mailing address:
  • Phone: 787-502-9459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberP7097
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: