Provider Demographics
NPI:1225025125
Name:NORRICK, DOUG M (OD)
Entity Type:Individual
Prefix:
First Name:DOUG
Middle Name:M
Last Name:NORRICK
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:712 CAMERON WOODS DR
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703
Practice Address - Country:US
Practice Address - Phone:260-665-3240
Practice Address - Fax:260-668-7953
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003327152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38626000Medicaid
IN201281190Medicaid
IN201281190Medicaid
WI0345670002Medicare NSC
WIV04098Medicare UPIN
IN160450035Medicare PIN
WI0345670004Medicare NSC
WI0345670001Medicare NSC
IN669220019Medicare PIN
WI000647545Medicare PIN