Provider Demographics
NPI:1134190747
Name:SODERBLOM, DOUGLAS (OD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:SODERBLOM
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 1:25815 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10169T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0101691Medicare ID - Type Unspecified
CAU45154Medicare UPIN
CA1116690001Medicare NSC