Healthcare Provider Details

I. General information

NPI: 1639701485
Provider Name (Legal Business Name): EDUARDO DIAZ RODRIGUEZ M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 04/30/2024
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE DEL CARMEN #9 (2DO. PISO) FAJARDO PUEBLO
FAJARDO PR
00738-0073
US

IV. Provider business mailing address

A29 CALLE MARGINAL
FAJARDO PR
00738-3759
US

V. Phone/Fax

Practice location:
  • Phone: 787-556-9937
  • Fax:
Mailing address:
  • Phone: 787-556-9937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6048
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: