Provider Demographics
NPI:1255754438
Name:DIAZ, DAVID (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:14405 W. COLFAX AVE
Mailing Address - Street 2:#310
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:80401
Mailing Address - Country:US
Mailing Address - Phone:303-522-7137
Mailing Address - Fax:303-302-6906
Practice Address - Street 1:2156 E. WILLIAMS FIELD RD.
Practice Address - Street 2:#104
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296
Practice Address - Country:US
Practice Address - Phone:480-814-2584
Practice Address - Fax:480-963-9591
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1957152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist