Provider Demographics
NPI:1114190154
Name:DIAZ, VICENTE ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:VICENTE
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 1:495 HAWLEY LN
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-1514
Mailing Address - Country:US
Mailing Address - Phone:203-375-5819
Mailing Address - Fax:
Practice Address - Street 1:495 HAWLEY LN
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-1514
Practice Address - Country:US
Practice Address - Phone:203-375-5819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251919207W00000X
CT048651207WX0108X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0108XAllopathic & Osteopathic PhysiciansOphthalmologyUveitis and Ocular Inflammatory Disease
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology