Provider Demographics
NPI:1962839076
Name:DIAZ, MARTIN V (OD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:V
Last Name:DIAZ
Suffix:
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 1:901 BYRNE ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-5547
Mailing Address - Country:US
Mailing Address - Phone:319-321-0776
Mailing Address - Fax:
Practice Address - Street 1:4812 VALLEY VIEW BLVD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-2018
Practice Address - Country:US
Practice Address - Phone:540-366-2208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2014-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002307152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0618002307OtherSTATE OF VIRGINIA DEPARTMENT OF HEALTH PROFESSIONS