Healthcare Provider Details

I. General information

NPI: 1740414291
Provider Name (Legal Business Name): MARYKNOLL DE LA PAZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARYNOLL DE LA PAZ MD

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 PONCE BYP STE 607
PONCE PR
00717-1379
US

IV. Provider business mailing address

30 CALLE FRESA
SAN JUAN PR
00926-5106
US

V. Phone/Fax

Practice location:
  • Phone: 787-284-4830
  • Fax: 787-284-4814
Mailing address:
  • Phone: 787-549-6651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number20224
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: