Provider Demographics
NPI:1720087737
Name:DIAZ, RAFAEL ANGEL (OD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:ANGEL
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 1:1050 SE MONTEREY RD
Mailing Address - Street 2:STE 103
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4512
Mailing Address - Country:US
Mailing Address - Phone:772-283-2020
Mailing Address - Fax:772-220-9582
Practice Address - Street 1:1050 SE MONTEREY RD
Practice Address - Street 2:STE 103
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4512
Practice Address - Country:US
Practice Address - Phone:772-283-2020
Practice Address - Fax:772-220-9582
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2170152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078796500Medicaid
FL19275BMedicare ID - Type Unspecified
FL078796500Medicaid