Provider Demographics
NPI:1003806696
Name:ATKINSON, DOUGLAS EDWARD (OD PLC)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:ATKINSON
Suffix:
Gender:M
Credentials:OD PLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9361 CHERRY VALLEY AVE SE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-9506
Mailing Address - Country:US
Mailing Address - Phone:616-891-4321
Mailing Address - Fax:
Practice Address - Street 1:9361 CHERRY VALLEY AVE SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-9506
Practice Address - Country:US
Practice Address - Phone:616-891-4321
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002843152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT33056Medicare UPIN
MI90OD165950Medicare ID - Type Unspecified