Healthcare Provider Details

I. General information

NPI: 1386379972
Provider Name (Legal Business Name): DIANA RODRIGUEZ OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7333 W THOMAS RD STE 18
PHOENIX AZ
85033-5547
US

IV. Provider business mailing address

4175 N FALCON DR APT 2023
GOODYEAR AZ
85395-2350
US

V. Phone/Fax

Practice location:
  • Phone: 623-247-0777
  • Fax:
Mailing address:
  • Phone: 317-771-0581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002598
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: