Provider Demographics
NPI:1396978573
Name:DOUGLAS FAMILY EYECARE, INC.
Entity type:Organization
Organization Name:DOUGLAS FAMILY EYECARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR. OF OPTOMETRY
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:330-394-2020
Mailing Address - Street 1:5000 E MARKET ST STE 5
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-2259
Mailing Address - Country:US
Mailing Address - Phone:330-394-2020
Mailing Address - Fax:
Practice Address - Street 1:5000 E MARKET ST STE 5
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2259
Practice Address - Country:US
Practice Address - Phone:330-394-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-03
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5534152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDO4275701Medicare PIN
OHDO4163442Medicare PIN
OHDO9385051Medicare PIN