Provider Demographics
NPI:1154383172
Name:DAZA, XIMENA MARIA (OD)
Entity type:Individual
Prefix:
First Name:XIMENA
Middle Name:MARIA
Last Name:DAZA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31119 MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544
Mailing Address - Country:US
Mailing Address - Phone:510-471-1234
Mailing Address - Fax:510-471-7414
Practice Address - Street 1:31119 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544
Practice Address - Country:US
Practice Address - Phone:510-471-1234
Practice Address - Fax:510-471-7414
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10308T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist