=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609070978
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. EDIL JOSUE AGOSTO DIAZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 03/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CALLE # 3 KM 8.3 HOSPITAL DR. FEDERICO TRILLA
-----------------------------------------------------
City | CAROLINA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-757-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | H53 CALLE 6 EL CONQUISTADOR
-----------------------------------------------------
City | TRUJILLO ALTO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00976-6419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 25646
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------