Provider Demographics
NPI:1700863396
Name:JURRIAANS, DONALD L (OD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:L
Last Name:JURRIAANS
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:PO BOX 331
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36202-0331
Mailing Address - Country:US
Mailing Address - Phone:256-237-4881
Mailing Address - Fax:256-237-2051
Practice Address - Street 1:519 LEIGHTON AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-5741
Practice Address - Country:US
Practice Address - Phone:256-237-4881
Practice Address - Fax:256-237-2051
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS301TA111152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000059537Medicaid
AL51059537OtherBC BS
630496921OtherEIN
000059537Medicare ID - Type Unspecified
T68951Medicare UPIN
630496921OtherEIN