Provider Demographics
NPI:1154300309
Name:SEREX-DOUGAN, DIANE (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:SEREX-DOUGAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7954 HARFORD RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-5838
Mailing Address - Country:US
Mailing Address - Phone:443-629-5459
Mailing Address - Fax:
Practice Address - Street 1:7954 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21234-5838
Practice Address - Country:US
Practice Address - Phone:443-629-5459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-14
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA849152WV0400X
MDTPA0849152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy