Provider Demographics
NPI:1205528296
Name:SMITH, DIANA (DO6088)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO6088
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20469 TORRE DEL LAGO ST
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-6316
Mailing Address - Country:US
Mailing Address - Phone:954-729-4416
Mailing Address - Fax:
Practice Address - Street 1:19975 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-2268
Practice Address - Country:US
Practice Address - Phone:239-590-0313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO6088156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician