Provider Demographics
NPI:1750639126
Name:DIAZ, LESLIE KENT SR (OD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:KENT
Last Name:DIAZ
Suffix:SR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4150 TAMIAMI TRL S
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5130
Mailing Address - Country:US
Mailing Address - Phone:941-497-5555
Mailing Address - Fax:941-497-2369
Practice Address - Street 1:4150 TAMIAMI TRL S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5130
Practice Address - Country:US
Practice Address - Phone:941-497-5555
Practice Address - Fax:941-497-2369
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL001028152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist