Provider Demographics
NPI:1952360182
Name:PATTEN, DOUGLAS R (OD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:PATTEN
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 1:136 N MAAG AVE
Mailing Address - Street 2:STE D
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-2250
Mailing Address - Country:US
Mailing Address - Phone:209-847-1121
Mailing Address - Fax:
Practice Address - Street 1:136 N MAAG AVE
Practice Address - Street 2:STE D
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-2250
Practice Address - Country:US
Practice Address - Phone:209-847-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6600T152W00000X
IDODP-594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0272510001Medicare NSC
CASD0066000Medicare PIN