Provider Demographics
NPI:1093797011
Name:DIAZ, CARLOS ELVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:ELVIN
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 1:4800 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4701
Mailing Address - Country:US
Mailing Address - Phone:602-955-1000
Mailing Address - Fax:602-508-4830
Practice Address - Street 1:1515 S 8TH ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-4940
Practice Address - Country:US
Practice Address - Phone:575-544-3937
Practice Address - Fax:575-546-2870
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2014-0132207W00000X, 207WX0009X
AZ48484207W00000X, 207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ163113OtherMEDICARE PIMA PTAN
NMMD2014-0132Medicaid
AZ878342Medicaid
TXTXB110251Medicare PIN