Provider Demographics
NPI:1700218930
Name:CORREA-DIEGUEZ, JOSE MIGUEL (OD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MIGUEL
Last Name:CORREA-DIEGUEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 25TH AVE N STE 3
Mailing Address - Street 2:
Mailing Address - City:TEXAS CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77590-4666
Mailing Address - Country:US
Mailing Address - Phone:409-945-5511
Mailing Address - Fax:409-945-5385
Practice Address - Street 1:2506 25TH AVE N STE 3
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77590-4666
Practice Address - Country:US
Practice Address - Phone:409-945-5511
Practice Address - Fax:409-945-5385
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-30
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8288-T152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX326469ZMACMedicaid