Provider Demographics
NPI:1265408371
Name:DIAZ, MARIA I (OD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:I
Last Name:DIAZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:64 THOMPSON ST
Mailing Address - Street 2:SUITE B104
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-5707
Mailing Address - Country:US
Mailing Address - Phone:203-469-1012
Mailing Address - Fax:203-467-1369
Practice Address - Street 1:64 THOMPSON ST
Practice Address - Street 2:SUITE B104
Practice Address - City:EAST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-5707
Practice Address - Country:US
Practice Address - Phone:203-469-1012
Practice Address - Fax:203-467-1369
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2426152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004173598Medicaid
CT090002426CT12OtherANTHEM BCBS
CT544893OtherCONNECTICARE
410000874Medicare ID - Type Unspecified
CT004173598Medicaid
CT544893OtherCONNECTICARE
CT1265408371Medicare NSC