Provider Demographics
NPI:1407908692
Name:HOLLABAUGH, DOUGLAS J (OD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:HOLLABAUGH
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 1:899 EMBARCADERO DR
Mailing Address - Street 2:STE 3
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-4094
Mailing Address - Country:US
Mailing Address - Phone:916-939-6631
Mailing Address - Fax:
Practice Address - Street 1:899 EMBARCADERO DR
Practice Address - Street 2:STE 3
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-4094
Practice Address - Country:US
Practice Address - Phone:916-939-6631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9879TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU46132Medicare UPIN
CASD0098790Medicare ID - Type Unspecified