Provider Demographics
NPI:1386379972
Name:RODRIGUEZ, DIANA (OD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:RODRIGUEZ
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 1:4175 N FALCON DR APT 2023
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2350
Mailing Address - Country:US
Mailing Address - Phone:317-771-0581
Mailing Address - Fax:
Practice Address - Street 1:7333 W THOMAS RD STE 18
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-5547
Practice Address - Country:US
Practice Address - Phone:623-247-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002598152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist