Healthcare Provider Details

I. General information

NPI: 1861672156
Provider Name (Legal Business Name): DIAZ VISION CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 E BANDERA RD SUITE 404
BOERNE TX
78006-2849
US

IV. Provider business mailing address

124 E BANDERA RD SUITE 404
BOERNE TX
78006-2849
US

V. Phone/Fax

Practice location:
  • Phone: 830-249-8400
  • Fax: 830-249-8411
Mailing address:
  • Phone: 830-249-8400
  • Fax: 830-249-8411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberL3624
License Number StateTX

VIII. Authorized Official

Name: DR. CARLOS ELVIN DIAZ
Title or Position: MD/OWNER
Credential: M.D.
Phone: 830-249-8400