Provider Demographics
NPI:1609192707
Name:DELATORRE, MOSES DIAZ (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:MOSES
Middle Name:DIAZ
Last Name:DELATORRE
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 W ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75233-1106
Mailing Address - Country:US
Mailing Address - Phone:469-531-7114
Mailing Address - Fax:
Practice Address - Street 1:2424 W ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-1106
Practice Address - Country:US
Practice Address - Phone:469-531-7114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$Medicaid