Provider Demographics
NPI:1417215948
Name:DOUGLAS R FINGOLD
Entity Type:Organization
Organization Name:DOUGLAS R FINGOLD
Other - Org Name:TEXAS STATE OPTICAL DICKINSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:FINGOLD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:281-534-4600
Mailing Address - Street 1:19052 GULF FWY
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-2703
Mailing Address - Country:US
Mailing Address - Phone:281-486-5064
Mailing Address - Fax:281-282-9885
Practice Address - Street 1:3010 GULF FWY S
Practice Address - Street 2:SUITE L
Practice Address - City:DICKINSON
Practice Address - State:TX
Practice Address - Zip Code:77539-4337
Practice Address - Country:US
Practice Address - Phone:281-534-4600
Practice Address - Fax:281-534-4699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-03
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03270TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX346113901Medicaid