Provider Demographics
NPI:1376865188
Name:JAMES KENT DOUB OD PA
Entity Type:Organization
Organization Name:JAMES KENT DOUB OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:DOUB
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-722-2042
Mailing Address - Street 1:2804 REYNOLDA RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3102
Mailing Address - Country:US
Mailing Address - Phone:336-722-2041
Mailing Address - Fax:336-777-8842
Practice Address - Street 1:2804 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3102
Practice Address - Country:US
Practice Address - Phone:336-722-2041
Practice Address - Fax:336-777-8842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-20
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1330152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916244Medicaid
NCDR5778Medicare PIN
NC2466723GMedicare PIN