Provider Demographics
NPI:1740266410
Name:VIS, DOUGLAS I (DPM)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:I
Last Name:VIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4056 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:OH
Mailing Address - Zip Code:44081-8657
Mailing Address - Country:US
Mailing Address - Phone:440-259-8120
Mailing Address - Fax:440-259-8186
Practice Address - Street 1:4056 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OH
Practice Address - Zip Code:44081-8657
Practice Address - Country:US
Practice Address - Phone:440-259-8120
Practice Address - Fax:440-259-8186
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003192213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2191293Medicaid
OH4027681Medicare PIN
OHU80950Medicare UPIN