Provider Demographics
NPI:1396741633
Name:DOOLIN, GEORGE WILLIAM JR (OD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:WILLIAM
Last Name:DOOLIN
Suffix:JR
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 1:15933 CLAYTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0838
Practice Address - Street 1:417A RACETRACK RD NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-4600
Practice Address - Country:US
Practice Address - Phone:850-315-8861
Practice Address - Fax:850-864-2844
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1405152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL593537436OtherTRICARE
A11078OtherEYEMED
FL19465OtherBLUECROSSBLUESHIELD
BN777ZMedicare PIN
T85227Medicare UPIN
FL593537436OtherTRICARE
FLDO9945OtherMEDICARE RR
BN777ZMedicare PIN
FL1251170001Medicare NSC