Provider Demographics
NPI:1700512670
Name:DIAZ AGUAYO, DENISE
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:DIAZ AGUAYO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 POLLARD RD STE 208
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1435
Mailing Address - Country:US
Mailing Address - Phone:408-378-1701
Mailing Address - Fax:
Practice Address - Street 1:825 POLLARD RD STE 208
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1435
Practice Address - Country:US
Practice Address - Phone:408-378-1701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003924152W00000X
CAOPT35772-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOEG003924OtherLICENSE
CAOPT35772--TLGOtherLICENSE