Provider Demographics
NPI:1073121430
Name:DIEZ, ELVIRA R
Entity Type:Individual
Prefix:
First Name:ELVIRA
Middle Name:R
Last Name:DIEZ
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 1:950 BLUEWOOD TER
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33327-2049
Mailing Address - Country:US
Mailing Address - Phone:954-822-9728
Mailing Address - Fax:
Practice Address - Street 1:950 BLUEWOOD TER
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33327-2049
Practice Address - Country:US
Practice Address - Phone:954-822-9728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO5566156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician