Provider Demographics
NPI:1972637767
Name:DIAZ, CARLOS ANTONIO (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:ANTONIO
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:IC 14 B LOMAS VERDES AVE
Mailing Address - Street 2:PMB 165
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956-3116
Mailing Address - Country:US
Mailing Address - Phone:787-798-5563
Mailing Address - Fax:787-787-3524
Practice Address - Street 1:IC 19 LOMAS VERDES AVE
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-3116
Practice Address - Country:US
Practice Address - Phone:787-798-5563
Practice Address - Fax:787-787-3524
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8977207VX0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
E63392Medicare UPIN
PR0080913Medicare ID - Type Unspecified