Provider Demographics
NPI:1669055588
Name:DOUGLASS, CHLOE CAROLYN (OD)
Entity type:Individual
Prefix:DR
First Name:CHLOE
Middle Name:CAROLYN
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-2918
Mailing Address - Country:US
Mailing Address - Phone:207-990-4388
Mailing Address - Fax:
Practice Address - Street 1:955 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2918
Practice Address - Country:US
Practice Address - Phone:207-990-4388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT1045152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1417949678Medicaid