Provider Demographics
NPI:1114935426
Name:DOUGLAS, JOSEPH K (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:K
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5025 SHATTUCK RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2823
Mailing Address - Country:US
Mailing Address - Phone:989-752-7121
Mailing Address - Fax:989-752-6918
Practice Address - Street 1:5025 SHATTUCK RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603
Practice Address - Country:US
Practice Address - Phone:989-752-7121
Practice Address - Fax:989-752-6918
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004056152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJD004056OtherBLUE CROSS BLUE SHIELD
MI900G310840OtherBLUE CROSS BLUE SHIELD
MI1871699314OtherMEDICARE GROUP
MI4338380Medicaid
MI0994678OtherHEALTHPLUS OF MICHIGAN
MI1871699314OtherMEDICARE GROUP
0506690001Medicare NSC
MI4338380Medicaid