Provider Demographics
NPI:1386469666
Name:DIAZ, ESTEBAN GUILLERMO (LDO)
Entity type:Individual
Prefix:
First Name:ESTEBAN
Middle Name:GUILLERMO
Last Name:DIAZ
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 S ELLIS ST APT 1081
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-4958
Mailing Address - Country:US
Mailing Address - Phone:305-572-8300
Mailing Address - Fax:
Practice Address - Street 1:1607 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2507
Practice Address - Country:US
Practice Address - Phone:602-249-7272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLDO-003407156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician