Provider Demographics
NPI:1255333829
Name:RITCHIE, DOUGLAS FREDERICK (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:FREDERICK
Last Name:RITCHIE
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 1:1500 GRAND CENTRAL AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1079
Mailing Address - Country:US
Mailing Address - Phone:304-295-5025
Mailing Address - Fax:304-295-7178
Practice Address - Street 1:1500 GRAND CENTRAL AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1079
Practice Address - Country:US
Practice Address - Phone:304-295-5025
Practice Address - Fax:304-295-7178
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV636D152W00000X
WV21556208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150423000Medicaid
RI0815534Medicare ID - Type Unspecified
WV2315780002Medicare NSC
WV0150423000Medicaid