Provider Demographics
NPI:1760560130
Name:DOUGAL, JEFFREY ROGER (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ROGER
Last Name:DOUGAL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1201 N ROSE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-3939
Mailing Address - Country:US
Mailing Address - Phone:714-528-2566
Mailing Address - Fax:714-993-5369
Practice Address - Street 1:1201 N ROSE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-3939
Practice Address - Country:US
Practice Address - Phone:714-528-2566
Practice Address - Fax:714-993-5369
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4880T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT09806Medicare UPIN
CAP01015545Medicare PIN
CAWOP4880BMedicare PIN