Provider Demographics
NPI:1972704641
Name:DIAZ, JAVIER
Entity type:Individual
Prefix:MR
First Name:JAVIER
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
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 1 BOX 5352
Mailing Address - Street 2:
Mailing Address - City:COROZAL
Mailing Address - State:PR
Mailing Address - Zip Code:00783-9327
Mailing Address - Country:US
Mailing Address - Phone:787-859-3736
Mailing Address - Fax:
Practice Address - Street 1:CARR 152 KM 2 8
Practice Address - Street 2:BARRIO QUEBRADILLAS DE BARRANQUITAS
Practice Address - City:BARRANQUITAS
Practice Address - State:PR
Practice Address - Zip Code:00794
Practice Address - Country:US
Practice Address - Phone:787-857-7954
Practice Address - Fax:787-857-5249
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3911183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3894OtherPROFESSIONAL LICENSE