Provider Demographics
NPI:1285272898
Name:DIAZ GONZALEZ, CHAIMARIE
Entity type:Individual
Prefix:
First Name:CHAIMARIE
Middle Name:
Last Name:DIAZ GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 2 BOX 5395
Mailing Address - Street 2:
Mailing Address - City:PENUELAS
Mailing Address - State:PR
Mailing Address - Zip Code:00624-9692
Mailing Address - Country:US
Mailing Address - Phone:787-403-8711
Mailing Address - Fax:
Practice Address - Street 1:SANTA MARIA MEDICAL BUILDING
Practice Address - Street 2:SUITE 102 AVE. FERROCARRIL
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00718
Practice Address - Country:US
Practice Address - Phone:787-403-8711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear SupplierGroup - Single Specialty