=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750344602
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEBERTO R DIAZ-OTERO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2006
-----------------------------------------------------
Last Update Date | 09/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CMSCOOPERATIVO ROAD115 KM 24.6 OFFICE #3
-----------------------------------------------------
City | AGUADA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00602-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-868-5111
-----------------------------------------------------
Fax | 787-868-2305
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 250321
-----------------------------------------------------
City | AGUADILLA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00604-0321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-868-5111
-----------------------------------------------------
Fax | 787-868-2305
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 6290
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------