Provider Demographics
NPI:1720210297
Name:DIAZ PADRON, LIETA (OD)
Entity Type:Individual
Prefix:DR
First Name:LIETA
Middle Name:
Last Name:DIAZ PADRON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16328 SW 43RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-5328
Mailing Address - Country:US
Mailing Address - Phone:305-713-8170
Mailing Address - Fax:
Practice Address - Street 1:13780 SW 26TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-6302
Practice Address - Country:US
Practice Address - Phone:305-553-4921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00623900152W00000X
PR663152W00000X
PAOEG002184152W00000X
FLOPC4630152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101160100Medicaid