Provider Demographics
NPI:1376643445
Name:WINE, DOUGLAS J (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:J
Last Name:WINE
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 1:140 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2312
Mailing Address - Country:US
Mailing Address - Phone:419-394-2397
Mailing Address - Fax:419-394-2398
Practice Address - Street 1:140 W SPRING ST
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2312
Practice Address - Country:US
Practice Address - Phone:419-394-2397
Practice Address - Fax:419-394-2398
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3979152W00000X
OHT1670152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0916941Medicaid
OH4772210001Medicare NSC
OHU48102Medicare UPIN
OH0916941Medicaid
OH0756984Medicare PIN