Provider Demographics
NPI:1700879046
Name:MACHIELA, DOUGLAS JOHN (OD)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:JOHN
Last Name:MACHIELA
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 1:3704 VALLEY PARK WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-2333
Mailing Address - Country:US
Mailing Address - Phone:561-641-5741
Mailing Address - Fax:
Practice Address - Street 1:5493 10TH AVE N
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-2056
Practice Address - Country:US
Practice Address - Phone:561-439-0075
Practice Address - Fax:561-439-0413
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2245152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078761200Medicaid
U06389Medicare UPIN
19396Medicare ID - Type Unspecified