Provider Demographics
NPI:1073517611
Name:EGBERT, DOUGLAS E (O D)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:E
Last Name:EGBERT
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6557 BRANDT PIKE
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-3353
Mailing Address - Country:US
Mailing Address - Phone:937-236-1770
Mailing Address - Fax:937-236-4003
Practice Address - Street 1:6557 BRANDT PIKE
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-3353
Practice Address - Country:US
Practice Address - Phone:937-236-1770
Practice Address - Fax:937-236-4006
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4555152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0767382Medicare PIN
OHEG0767392Medicare ID - Type Unspecified
OH0767383Medicare PIN
OH0310550001Medicare NSC
OH0767381Medicare PIN
OHU51755Medicare UPIN
OH0310550004Medicare NSC
OH0310550003Medicare NSC