MEDICARE: LISSETTE DIAZ-SERRANO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	208D00000X	General Practice Physician	22344	PR

General Provider Information

NPI Number	:	1730755380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISSETTE DIAZ-SERRANO

Provider Business Mailing Address
First Line	:	2053 W BIRCHWOOD AVE APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-2173
Country	:	US
Telephone Number	:	773-706-6197
Fax Number	:

Provider Business Practice Location Address
First Line	:	2053 W BIRCHWOOD AVE APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-2173
Country	:	US
Telephone Number	:	773-706-6197
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2021
Last Update Date	:	04/22/2025

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Directions to “ LISSETTE DIAZ-SERRANO ” Practice Location

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