Basic Information
Provider Information | |||||||||
NPI: | 1093797011 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIAZ | ||||||||
FirstName: | CARLOS | ||||||||
MiddleName: | ELVIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4800 N 22ND ST | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850164701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029551000 | ||||||||
FaxNumber: | 6025084830 | ||||||||
Practice Location | |||||||||
Address1: | 1515 S 8TH ST | ||||||||
Address2: |   | ||||||||
City: | DEMING | ||||||||
State: | NM | ||||||||
PostalCode: | 880304940 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5755443937 | ||||||||
FaxNumber: | 5755462870 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2005 | ||||||||
LastUpdateDate: | 04/30/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD2014-0132 | NM | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207W00000X | 48484 | AZ | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207WX0009X | MD2014-0132 | NM | N |   |   |   |   | 207WX0009X | 48484 | AZ | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | Z163113 | 01 | AZ | MEDICARE PIMA PTAN | OTHER | MD2014-0132 | 05 | NM |   | MEDICAID | 878342 | 05 | AZ |   | MEDICAID |