Basic Information
Provider Information | |||||||||
NPI: | 1205030988 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZEQUEIRA DIAZ | ||||||||
FirstName: | JORGE | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | CC14 CALLE DAISY | ||||||||
Address2: |   | ||||||||
City: | SAN JUAN | ||||||||
State: | PR | ||||||||
PostalCode: | 009266314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7875041100 | ||||||||
FaxNumber: | 7872876190 | ||||||||
Practice Location | |||||||||
Address1: | CIRUGIA PEDIATRICA RCM | ||||||||
Address2: | HOSPITAL PEDIATRICO UNIVERSITARIO CENTRO MEDICO DE PR | ||||||||
City: | SAN JUAN | ||||||||
State: | PR | ||||||||
PostalCode: | 00935 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7877773535 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2007 | ||||||||
LastUpdateDate: | 01/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | 17,885 | PR | Y |   | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
No ID Information.