Provider Demographics
NPI:1518212539
Name:WIERSMA, DOUGLAS STEPHEN (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:STEPHEN
Last Name:WIERSMA
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 1:29885 SEQUOIA TRL
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5153
Mailing Address - Country:US
Mailing Address - Phone:440-376-1690
Mailing Address - Fax:
Practice Address - Street 1:1261 W ROYALTON RD
Practice Address - Street 2:
Practice Address - City:BROADVIEW HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44147-2407
Practice Address - Country:US
Practice Address - Phone:440-526-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6168152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty