Provider Demographics
NPI:1194576215
Name:DIA, LU'AIE HUSAM (STUDENT)
Entity type:Individual
Prefix:
First Name:LU'AIE
Middle Name:HUSAM
Last Name:DIA
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:772 NE AUTUMNCREEK WAY APT O208
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97006-8743
Mailing Address - Country:US
Mailing Address - Phone:806-674-7661
Mailing Address - Fax:
Practice Address - Street 1:1001 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-7017
Practice Address - Country:US
Practice Address - Phone:918-444-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK3257152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program