Healthcare Provider Details

I. General information

NPI: 1558032136
Provider Name (Legal Business Name): AMANDA M DIAZ MENDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 PLAZA 7 GRAN VISTA 2
GURABO PR
00778
US

IV. Provider business mailing address

67 PLAZA 7 GRAN VISTA 2
GURABO PR
00778
US

V. Phone/Fax

Practice location:
  • Phone: 787-692-1243
  • Fax:
Mailing address:
  • Phone: 787-692-1243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number37436
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: