Provider Demographics
NPI:1427729193
Name:DIAZ MENJIVAR, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:DIAZ MENJIVAR
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 1:24 LAYTON AVE PH
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-1429
Mailing Address - Country:US
Mailing Address - Phone:347-968-9070
Mailing Address - Fax:
Practice Address - Street 1:12 N. BROADWAY SUITE 2B
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701
Practice Address - Country:US
Practice Address - Phone:718-866-4569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist