Provider Demographics
NPI:1891045019
Name:DOUGLASS, JUSTIN ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROBERT
Last Name:DOUGLASS
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 1:1340 W GRAY ST
Mailing Address - Street 2:217
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77019-4059
Mailing Address - Country:US
Mailing Address - Phone:281-682-5209
Mailing Address - Fax:
Practice Address - Street 1:6704 STERLING RIDGE DR
Practice Address - Street 2:D
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77382-2799
Practice Address - Country:US
Practice Address - Phone:281-465-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8011152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist