Provider Demographics
NPI:1689712929
Name:MAR, DOUGLAS H (OD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:H
Last Name:MAR
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 1:1100 9TH AVE
Mailing Address - Street 2:MS:M4-PA
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:
Practice Address - Street 1:13014 120TH AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3015
Practice Address - Country:US
Practice Address - Phone:425-821-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001558152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAUS0861769OtherAETNA SPECIALIST PIN
WA2101103Medicaid
WAMA8570OtherBLUE SHIELD #
WA0039597OtherLABOR AND INDUSTRIES#
WAMA8570OtherBLUE SHIELD #
WA180038183Medicare PIN
WA0039597OtherLABOR AND INDUSTRIES#