Healthcare Provider Details

I. General information

NPI: 1467948976
Provider Name (Legal Business Name): CARLOS DAVID DIAZ PEREZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 07/25/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE EMETERIO BETANCES #64
MAYAGUEZ PR
00680
US

IV. Provider business mailing address

510 W 1ST AVE
TOPPENISH WA
98948-1564
US

V. Phone/Fax

Practice location:
  • Phone: 787-833-0885
  • Fax: 787-831-2177
Mailing address:
  • Phone: 509-865-5600
  • Fax: 509-865-5783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD61300346
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21955
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: