Healthcare Provider Details

I. General information

NPI: 1821321191
Provider Name (Legal Business Name): MIREYA M BOLO DIAZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR. 891, KM. 1.4, BO. PUEBLO
COROZAL PR
00783-2441
US

IV. Provider business mailing address

PO BOX 29828
SAN JUAN PR
00929-0828
US

V. Phone/Fax

Practice location:
  • Phone: 787-944-3337
  • Fax: 787-699-0039
Mailing address:
  • Phone:
  • Fax: 787-699-0039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18363
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number18363
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: