Provider Demographics
NPI:1467974865
Name:RILEY, DOUGLAS MARTIN (OWNER/OPTICIAN)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:MARTIN
Last Name:RILEY
Suffix:
Gender:M
Credentials:OWNER/OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3251
Mailing Address - Country:US
Mailing Address - Phone:919-368-0403
Mailing Address - Fax:
Practice Address - Street 1:115 MARKET ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-3251
Practice Address - Country:US
Practice Address - Phone:919-368-0403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC451156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC451OtherLICENSED OPTICIAN