Provider Demographics
NPI:1417949678
Name:DOUGLASS, DAVID THOMAS (OD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:THOMAS
Last Name:DOUGLASS
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 1:955 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-2918
Mailing Address - Country:US
Mailing Address - Phone:207-990-4388
Mailing Address - Fax:207-947-9241
Practice Address - Street 1:955 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2918
Practice Address - Country:US
Practice Address - Phone:207-990-4388
Practice Address - Fax:207-947-9241
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT757152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME243540099Medicaid
ME243540099Medicaid
ME1417949678Medicare PIN