Provider Demographics
NPI:1063600211
Name:DIAS, RAQUEL HURUTA (MD)
Entity type:Individual
Prefix:DR
First Name:RAQUEL
Middle Name:HURUTA
Last Name:DIAS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1305 POST RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6016
Mailing Address - Country:US
Mailing Address - Phone:203-955-1990
Mailing Address - Fax:203-955-1991
Practice Address - Street 1:1305 POST RD
Practice Address - Street 2:SUITE 103
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6016
Practice Address - Country:US
Practice Address - Phone:203-955-1990
Practice Address - Fax:203-955-1991
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT047845208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008004317Medicaid
CT1063600211Medicaid