Provider Demographics
NPI:1811236490
Name:DOUGLAS SODERBLOM, O.D.
Entity Type:Organization
Organization Name:DOUGLAS SODERBLOM, O.D.
Other - Org Name:LOMA LINDA OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SODERBLOM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-478-3345
Mailing Address - Street 1:25815 BARTON RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3893
Mailing Address - Country:US
Mailing Address - Phone:909-478-3345
Mailing Address - Fax:909-478-9337
Practice Address - Street 1:25815 BARTON RD
Practice Address - Street 2:SUITE 104
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3893
Practice Address - Country:US
Practice Address - Phone:909-478-3345
Practice Address - Fax:909-478-9337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-03
Last Update Date:2013-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10169TG261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care