Provider Demographics
NPI:1427578681
Name:FRUIN, DOUGLASS R (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLASS
Middle Name:R
Last Name:FRUIN
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 1:1825 N WINNEBAGO AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-6322
Mailing Address - Country:US
Mailing Address - Phone:308-380-7558
Mailing Address - Fax:
Practice Address - Street 1:2736 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1503
Practice Address - Country:US
Practice Address - Phone:773-248-8866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1467152W00000X
IL046.011575152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty