Provider Demographics
NPI:1144224791
Name:MIDDLETON, IAN JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:JAMES
Last Name:MIDDLETON
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 1:1559 FARMERS LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7525
Mailing Address - Country:US
Mailing Address - Phone:707-571-2020
Mailing Address - Fax:707-540-6299
Practice Address - Street 1:1559 FARMERS LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7525
Practice Address - Country:US
Practice Address - Phone:707-571-2020
Practice Address - Fax:707-540-6299
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5308T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0053080Medicaid
CASD0053080Medicaid
SD0053080Medicare ID - Type Unspecified