Provider Demographics
NPI:1174216626
Name:DIAZ, CHARLES EUGENE
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:EUGENE
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 LAND O LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-2930
Mailing Address - Country:US
Mailing Address - Phone:813-909-2598
Mailing Address - Fax:813-909-9381
Practice Address - Street 1:1575 LAND O LAKES BLVD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-2930
Practice Address - Country:US
Practice Address - Phone:813-909-2598
Practice Address - Fax:813-909-9381
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3848156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician