Provider Demographics
NPI:1699778621
Name:DIAZ, MICHELLE (OD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:DIAZ
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 1:99 US ROUTE 1 BYP STE A
Mailing Address - Street 2:
Mailing Address - City:KITTERY
Mailing Address - State:ME
Mailing Address - Zip Code:03904-1792
Mailing Address - Country:US
Mailing Address - Phone:072-439-0410
Mailing Address - Fax:207-439-8353
Practice Address - Street 1:99 US ROUTE 1 BYP
Practice Address - Street 2:
Practice Address - City:KITTERY
Practice Address - State:ME
Practice Address - Zip Code:03904
Practice Address - Country:US
Practice Address - Phone:207-439-0410
Practice Address - Fax:207-439-8353
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEAA549786OtherHARVARD
NH30009844Medicaid
NHRE4191Medicare ID - Type Unspecified