Provider Demographics
NPI:1013630581
Name:DIAZ, LUIS GERARDO (OD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:GERARDO
Last Name:DIAZ
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 1:25511 BUDDE RD STE 3801
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77380-4087
Mailing Address - Country:US
Mailing Address - Phone:281-419-3355
Mailing Address - Fax:
Practice Address - Street 1:25511 BUDDE RD STE 3801
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77380-4087
Practice Address - Country:US
Practice Address - Phone:281-419-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10663152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist