Provider Demographics
NPI:1578698668
Name:DR RICHARD DOUGLAS OD PC
Entity Type:Organization
Organization Name:DR RICHARD DOUGLAS OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:N
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:804-748-6983
Mailing Address - Street 1:4705 BUCKINGHAM CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-4282
Mailing Address - Country:US
Mailing Address - Phone:804-748-6983
Mailing Address - Fax:
Practice Address - Street 1:4705 BUCKINGHAM CT
Practice Address - Street 2:SUITE A
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-4282
Practice Address - Country:US
Practice Address - Phone:804-748-6983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000742152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU94802Medicare UPIN
VA5739810001Medicare NSC
VA00X026L01Medicare PIN