Provider Demographics
NPI:1396790671
Name:DIAZ, ORLANDO A (OD)
Entity type:Individual
Prefix:DR
First Name:ORLANDO
Middle Name:A
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 1:114 RENE PL
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-8980
Mailing Address - Country:US
Mailing Address - Phone:405-473-3937
Mailing Address - Fax:
Practice Address - Street 1:660 SW 19TH ST STE G
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-5406
Practice Address - Country:US
Practice Address - Phone:405-794-0176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1153152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100761630AMedicaid
OK100761630AMedicaid