=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396790671
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ORLANDO A DIAZ OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2006
-----------------------------------------------------
Last Update Date | 09/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 660 SW 19TH ST STE G
-----------------------------------------------------
City | MOORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73160-5406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-794-0176
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 RENE PL
-----------------------------------------------------
City | SHAWNEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74804-8980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-473-3937
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1153
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------