Robert Dean Douglas
Individual provider Active NPI Optometrist · Ravenna, MI
NPI 1861516239 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1861516239
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Optometrist 152W00000X
- License
- MI3937 (MI)
- Practice address
- 12412 Stafford St
Ravenna, MI 48451-0307 - Phone
- (231) 853-6459
- Fax
- (231) 853-6459
- NPI assigned
- Mar 19, 2007
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MI3937 | MI | MD | Optometrist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | MI3937 | MI | Yes |
Addresses
Primary practice location
12412 Stafford St
Ravenna, MI 48451-0307
Mailing address
PO Box 307
12412 Stafford St
Ravenna, MI 49451-0307
Phone (231) 853-6459
Other providers in Ravenna, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.