Provider Demographics
NPI:1942533153
Name:DOUGLAS, KIMBERLY MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:MARK
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15640 DON LOCHMAN LN STE C
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4442
Mailing Address - Country:US
Mailing Address - Phone:704-943-5110
Mailing Address - Fax:704-943-4449
Practice Address - Street 1:15640 DON LOCHMAN LN STE C
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4442
Practice Address - Country:US
Practice Address - Phone:704-943-5110
Practice Address - Fax:704-943-4449
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2257152W00000X
VA0618001906152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMM2643559OtherDEA
NCNC9783B884Medicare PIN